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Burnett Coufrty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm o 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 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the g <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. <br /> / H m <br /> J, g6I19ry ¢ JAwrct a7 Sgnf e a E <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> lR7/5 .q el <br /> Address Address 1 �� <br /> Fi4 /V5-5-v 2 5�_ <br /> City, State, Zip ode City,State,Zip Code <br /> Tele one` s --r� �J Telephone <br /> --II �� <br /> Emergency/Fire No. and bad Name <br /> Legal Description (as indicated on tax statement) <br /> n_ L7 <br /> Permitos) Applied for: <br /> w r <br /> Dwelling � Addition Filling/Grading Camping Unit o <br /> Z o 1 <br /> Accessory Building Sanitary __X Privy Subdivision } <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garAge, additio , etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). C 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft.,and the location of any river or stream- if within In <br /> c <br /> 300 ft. Z <br /> Z0 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 ()) o <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 CN <br /> dated by the owner. �i m <br /> PLOT PLAN <br /> V, x" e m <br /> o` <br /> m <br /> o <br /> w <br /> t�J <br /> Z <br /> I II77 <br /> m o c ro m n n 7 m <br /> o m < <br /> goo 0. 00 <br /> P i i T N i m <br /> L" [ G) o <br /> F, <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know) S [ 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 E m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. $ $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ay, <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have N o <br /> access to the above described premises a ny reasonable time for the purpose of inspection. w $ <br /> m 3 A x : <br /> SIGN HERE - - - ` P E <br /> (signature of owner r buildin c tr tor '`_r <br /> ZONING ADMINISTRATOR :) kcn <br /> TOWNSHIP PER ITS MAY BE REQUIREp' — 2 �� IUt N O <br />