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()r-) J <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 'u a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m ' \\ <br /> m c lJ <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 a <br /> regulations of the State of Wisconsin. /� m m <br /> (�is n Imo- OU GI 1, �a n.e a o <br /> OWNER Please Print E <br /> { Contractor or urveyor or Agent o <br /> a7a� E edits Lk. Rd , '1 R-]s a;f� T�nrf-nr LK K� <br /> Add e s r Adds <br /> U _ <br /> City, State, Zip Code City, State, Zip Code j(� <br /> Telephone Telephone �J <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> n � <br /> 0 <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit o °— <br /> Z v <br /> o ° <br /> Accessory Building Sanitary Privy Subdivision m <br /> Garage <br /> Structure Use: r <br /> 0 <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 (ES) and all new buildings (NB) and indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST), and draiMield (DF). 0 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 u,t� <br /> 300 ft. ` <br /> o n 7\ <br /> 4. Show dimensions infeet ofthefollowing:(a) buildingto all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. M o (� <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. <br /> m <br /> PLOT PLAN � <br /> 1 � <br /> CC O <br /> ( J � <br /> J o <br /> p �c�o / off <br /> N <br /> m <br /> a � <br /> w <br /> , z <br /> f <br /> W c � m m ., fn <br /> oa am ]o <br /> c o m 3 <br /> Z m o e 0 : 1 <br /> 02111 <br /> fes : ZZ m <br /> G) m <br /> c� � o <br /> ' g � : <br /> m c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- (`' S . <br /> gym : 11 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- m.e [ O <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 f o, E <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m g f <br /> ry R AA <br /> N H 8 <br /> SIGN HERE . w H <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED U"N o o m <br /> 88 $ 88888ai <br />