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r <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein. The 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 Wisconsin. H _o <br /> IP��ITI. bo )fes ���� n � v O <br /> � <br /> f <br /> OWNER (Please Pr' Contractor or Surveyor or Agent o <br /> I JOS L,Mes f-d <br /> Awe l e '^f 1 �_. Address <br /> ity, Stat Zi Code V l City,State,Zip Code <br /> is & _ <br /> Telephonen Telephone <br /> 7/� G awez <br /> Emergent /Fire No. and Road Name <br /> •( <br /> Legal Description (as indicated on tax statement) <br /> n 0 <br /> 0 <br /> Permit(s)Applied for: 0 �- <br /> Dwelling Addition Filling/Grading Camping Unit B <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o } <br /> Garage /nom n r <br /> Structure Use: / C� `-/ o <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). <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 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 o <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 N <br /> to lake, river or stream, if applicable. 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 01 <br /> dated by the owner. m <br /> PLOT PLANI e <br /> Lo . jou&15 ed 3°OrX <br /> f <br /> P00 O s <br /> f GArzpb F <br /> IDS R� Qj <br /> � <br /> ' .2& X46 <br /> L o <br /> C. o <br /> I , A 0 I� <br /> t .2y U <br /> ( o <br /> ( X pQ,aa <br /> �FIE� <br /> V) N � ry� r DD O V <br /> o c -. 0 to . c, F m <br /> m Dom am M <br /> - K <br /> z o2ommN � 0 0(see <br /> C <br /> 0 9 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 <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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. a <br /> m 3 <br /> fA N O <br /> SIGN HERE <br /> (sign r of owner or building contractor) (date) o s <br /> ZONING ADMINISTRATOR �� g <br /> d1M �Hd1WM �, <br /> TOWNSHIP PERMITS MAY BE REQUIRED8 8^^ ^ o ^ S m <br /> (li (li tli N N O O <br /> 8ggg88gg ) <br />