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Burnett'County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITSd 3_ <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. TDe undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wis onsin. y m <br /> ecat� g� <br /> M 0 <br /> F <br /> OWNER (Pleas Print) Contractor or Surveyor or Agent o to <br /> 'E � Ce Ric RS� m <br /> Addr s Address ' O <br /> Ivoow`t� i _ y$6 <br /> City, St e,Zip Code City, State, Zip Code <br /> j <br /> Telephone Telephone _. <br /> d3s'- 822 (3s-3o7 % <br /> I <br /> Emergency Ire Na. andRoad aloe (_ <br /> JN sw / y rRwk <br /> Legal Description (as indicated on fax statement) o <br /> n L1 Q <br /> Permit(s) Applied for: °- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> `( Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> � y.� n <br /> Structure Use: a <br /> (family home/cabin, garage, addition, etc.) ll'I <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). <br /> 2. Show the location of the well (N),septic tank (ST),and drainfield (DF). G 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 P <br /> 300 ft. o n <br /> 4. Show dimensions in feet of the following: (a) building to all lot lines,(b)building to center line of road,(c)building m � H <br /> to lake, river or stream, if applicable. o` <br /> 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. 14 �J <br /> m L <br /> PLOT PLAN C <br /> S11-041- <br /> I <br /> BEd BF L��E 0 <br /> goo <br /> DDO <br /> m o - m m a, f m <br /> 1 .1 ll��aJJ 9^ G <br /> ` ' N O SF <br /> fI00 � 0 �p <br /> 0()e*. <br /> G) D <br /> I declare that this application(including any accompanying schedule)has been examined me and to the best of my knowl- o 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 informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognizethat this infor <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m g <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 vI <br /> access to the abovy described premises at any reasonable time for the purpose of inspection. w g m <br /> m E 3 n <br /> m a n ie <br /> ' H N <br /> SIGN HERE d' .n <br /> (si ure o er or building contractor) (date) ti o x <br /> ZONING ADMINISTRATOR <br /> JH'N N O H H <br /> TOW <br /> ` NSHIP PERMITS MAY BE REQUIRED T'�T NIN o 0 <br /> 8' 8888 <br /> U <br />