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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE.ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <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 n <br /> regulations of the State of Wisconsin. �, 7 <br /> ` O <br /> 'Dn��� L�ES� ��o S.R.rla�6�l a f <br /> OWNER (PIePfint �K�LI Contractor or Surveyor or Agent o <br /> I`���� ESN d <br /> Address Address <br /> MW .5S Lbs <br /> CitState, Zip Code City,State, Zip Code <br /> L1i - fly— goo,4 <br /> Telephone O 10 MIS RD Telephone ( 7t, <br /> 'LSI • � <br /> Emergency/Fire No. and Road Name Ih <br /> Legal Description (as indicated on tax statement) <br /> o (� <br /> Permit(s) Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision o } 17 <br /> Garage <br /> Structure Use: SP0,-1V1 �/� IIj t h • G <br /> (fami home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: MW (A :� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 t <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within on <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 m � <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 C <br /> dated by the owner. M ! e <br /> PLOT PLAN O I fS'1 <br /> CA <br /> b <br /> 0 <br /> 0 <br /> o � <br /> N <br /> ^ <br /> �1 Z <br /> G <br /> N. <br /> 0.c <br /> o m0. <br /> o F g TZ <br /> . m m <br /> g c . <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- n o : 1D `� m <br /> X� = . <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. �' w <br /> mation I 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 maybe 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 c„ o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> m 3 n <br /> 81 s <br /> SIGN HERE '� <br /> (sign"att�ulr 0, f oownerroor building contractor) � (date) <br /> �w o x <br /> ZONING ADMINISTRATOR `-'rTtr'�� T CI)'(A) g <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> $ 888 m <br />