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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 00 0 o 0 <br /> '- 3 <br /> APPLICATION FOR — LAND USE — PERMITS m o <br /> TO rHE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m (Jl <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. m m° OL <br /> i � L /� M - z - c /� s v LG PjELF a o f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> m <br /> Address ✓'i C� �) X142 4 L o -F- GAddrT� A � <br /> City, State, Zip Code C �f l City, State, Zip Code r, <br /> I r <br /> X79 <br /> Telepho a hleLAM �Vi1LVJLj 2$10 phone ) <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> 0 <br /> Permit(s) Applied for: 0 o <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Zo <br /> Accessory Building Sanitary Privy Subdivision P } <br /> Garage — <br /> n <br /> Structure Use: O r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream-if within q 9 <br /> 300 ft. 0 1 a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. I 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C L <br /> dated by the owner. m QQ c <br /> PLOT PLAN a <br /> ��IT�IC-tFE� d cs <br /> 1 � � C5 N <br /> o <br /> N c I� <br /> m o c m m n a m <br /> -Z goo no <br /> Ems : Tcn : : m <br /> V, 0 <br /> .f" m C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- '^0 m '� i m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- wN 3 w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Oro <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ m $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have O ut o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ m <br /> T 3m : <br /> m v A w <br /> SIGN HERE lee <br /> D —'• N <br /> (signature of owner 0r building contractor) (d e) <br /> ZONING ADMINISTRATOR <br /> • <br /> E REQUIREDTOWNSHIP PERMITS MAY NMNN�e81m <br /> $ $0888T <br /> m <br />