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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M o a <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 0 `m v, <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and '- <br /> regulations of the State of Wisconsin. '' ll m m <br /> J)kNNIS �CkK P, a $ <br /> OWNER (Please Pr''t) 1 / Contractor or Surveyor or Agent o <br /> oZ qcZ-��. 7"�NE /\/NCL hAhI C- <br /> Adgqress Address <br /> bJFR� �_5��.3� <br /> City, State, Zip Co e / City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) ° <br /> a <br /> 0 <br /> Permit(s) Applied for: 0 < <br /> Dwelling Addition Filling/Grading Camping Unit B <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P m <br /> Garage <br /> Structure Use: I 'p o <br /> (family home/cabin arage, addition, etc.) Mill <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). M <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). v m <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if withinan <br /> /I 11i1 <br /> 300 ft. o n W <br /> 4. Show dimensions infeet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building m w <br /> to lake, river or stream, if applicable. <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. (, <br /> . <br /> PLOT PLAN / =j <br /> �iday �ra17) LQ �e <br /> 17-/(,- 77 <br /> ` <br /> 73- <br /> s <br /> O � y <br /> fv Z <br /> I � <br /> D 'n 'n '0 D D O 17 <br /> m. aa4 jL100 nm M <br /> o < Z m o 0. ,'0 3 <br /> Z m o <br /> r� = m <br /> C <br /> u n c i <br /> g m <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- a <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E 25 'm [ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m $ m <br /> m 3 <br /> a m : <br /> m E v m [ <br /> SIGN HERE / y1,2' ✓ / - 91 <br /> a <br /> (signature of owner or buldin ontr tor) _ (date) o x <br /> ZONING ADMINISTRATOR A <br /> (pNNON M <br /> TOWNSHIP P RMITS MAY BE REQUIRED N PRI N N O m <br /> 88888 8 vmT <br /> ) <br />