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c` 1 �t�� J <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w 1 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <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. n <br /> regulations of the State of Wisconsin. J H m }Q <br /> (7Ec`m2/ )pCj l� n13 L� CA7�Sr ICK C.UNN!/i n �� <br /> O r`1 NER ((P� ase Print) Contractor or Surveyor or Agent o <br /> / l r ;Z, V,9 SHu rr4r.=cpejn7rt- r?r0 <br /> Address Ad ress <br /> to �QSTE•z w, svx 9 3 - e1? 6 I 601 Yy17 -L- <br /> City, <br /> � <br /> City, State,Zip Code City, tate, Zip Code O <br /> I G G - -/ c7 S,Cr- --Z 0 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> � L7 <br /> Permit(s) Applied for: <br /> N r <br /> Dwelling Addition X— Filling/Grading Camping Unit S °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage //n�' // <br /> Structure Use: 04&6& <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X 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 11 o 0 <br /> 300 ft. z a <br /> 0 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 77SS�� m <br /> to lake, river or stream, if applicable. m w 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. m <br /> PLOT PLAN �.ee �,/[_ /_ _ J "9174 <br /> �jr%aGIL�( f r ( <br /> O <br /> I N <br /> `FJ � <br /> o <br /> O � <br /> N <br /> 0 <br /> Z <br /> < 1 <br /> D o in m d DDn017 <br /> tD F m <br /> m, DK,� "n0 a- <br /> <. <br /> p <br /> < = m 000 0 <br /> 0 <br /> z o <br /> o f 0 �! rn 71 <br /> m <br /> 8 <br /> c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 `� a <br /> v _ 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- — F» m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mationI 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 0, <br /> access to the above described premises at any reasonable time for the purpose of inspection. w g <br /> m ' 3 0 <br /> m 7 A m <br /> PP .. <br /> � l...CAMM <br /> SIGN HERE` I f^ a <br /> ( ' n ure of own buildi ontractor) / r(date) <br /> ZONING ADMINISTRATOR g : <br /> TOWNSHIP RMITS X0N0NNMAY BE REQUIRED 0N O .9t9888p <br />