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CD B9 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator cn d A o 0 <br /> APPLICATION FOR — LAND USE —,PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the yrork described and rn a <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. �, d <br /> ]]1 I n <br /> OWNER aPrint) ( Contractor or Surveyor or Agent o <br /> Address / Address <br /> City, State,Zip Code City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name ` �l <br /> 07/30 L/ c/f d C- <br /> Legal Description (as indicated on tax statement) q <br /> O <br /> Permit(s)Applied for: o °< <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o' <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: .�/� 3 secwv Yd� lr6Lr'( ICDorw` <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). 31 O <br /> 2. Show the location of the well (W),septic tank (ST), and drainflaid (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 m <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 <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. (A <br /> m <br /> PLOT PLAN 0 -Q'- <br /> , l' I <br /> a. Uo �) y <br /> i _ r <br /> iJ <br /> L. 4 <br /> q I D o c m m ¢ O V <br /> < < C m o o <br /> 7 !• Z N oIn <br /> m -i <br /> g : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best ofmy know) o tD Zm <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- d,d p <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. I 8 m <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- N <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 8 m <br /> / A <br /> SIGN HERE rC C.lL. G' L� �.C.'. Zq a. - � - <br /> (s' n ure of owner or Id, g co ractor) (date) <br /> ZONING ADMINISTRATOR — "[ 8 <br /> C W Hi�+(A diM(R T <br /> TOWNSHIP PERMITS MAY BE REQUIRED t c. uNi N N o o s m <br /> 888888 $ 8rmn <br />