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6) _r, IJ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d o <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 '^ m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0. <br /> regulations of the State of Wisconsin. y m <br /> m <br /> '�nr�.i Gaa r,rr �p a ° <br /> f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> J�^] /l j /k 'e rV ct !nC I r m <br /> Address t Address <br /> Qy 'L 7 <br /> City, State,Zi Code City, State,Zip Code o <br /> IJ ho� � <br /> Tele hone Telephone � <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n O <br /> 0 <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit ° g <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage Ul <br /> Structure Use: &(J 1 r) Lohr <br /> family ho a/cabin, garage, addition, etc.) o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 4' <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (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 P c <br /> 300 ft. o <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 H <br /> to lake, river or stream, if applicable. `; ZIm <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 /> R� <br /> V N <br /> m <br /> O <br /> J <br /> O <br /> J ^, <br /> O � <br /> / r Z <br /> 5 �/ly Ti <br /> r <br /> D o c . m w . a : M <br /> m <br /> o - - <br /> A < w 0 Z 3 <br /> o J ea i <br /> Z o Z <br /> m <br /> i GJ � i O <br /> li 8ii ac ' C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m ci m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 m 8 <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 O u, o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ o <br /> m 3 n <br /> m a >m <br /> m m <br /> SIGN HERE a <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR I11G(ol(1 g <br /> TOWNSHIP PERMITS MAY BE REOUIRED m <br /> V T N 4 O O <br /> 88888888rmn <br />