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i�'31r �'iill � <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn M 0 9 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v N > <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 X <br /> regulations of the State of Wisconsin. y <br /> DI) Aalrl <br /> n £ <br /> OWNER 'Pleas int) Contractor or Surveyor or Agent o <br /> Addr s <br /> Address <br /> City, State, Zip Code r City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> 0 <br /> Permit(s) Applied for: ° ,- <br /> Dwelling Addition` Filling/Grading Camping Unit ° (� <br /> v <br /> Z o <br /> Accessory Buildi Sanitary Privy Subdivision <br /> Garage y <br /> Structure Use: J LJQ <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 00 <br /> O <br /> 2. Show the location of the well (W),septic tank (ST), and drainf laid (DF). <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 c <br /> 300 ft. 0 <br /> o a <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 3 <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 C <br /> dated by the owner. 1A a' <br /> PLOT PLAN <br /> i <br /> n <br /> 0 <br /> / � m <br /> _ <br /> 0 C y r D D O M <br /> o c . m d o n f m <br /> '— 'n N <br /> o <br /> N s <br /> P s � : : T --: m <br /> x �n c) g o <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- I=) 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 informa- <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 li 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- -P d, <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. -7-2 <br /> SIGN HERE <br /> a : <br /> (si t e of own buildin c tractor) (date) ,)j o x. <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP RMITS MAY BE REOUIRED ^lo"S u� N o 8 9 m <br /> $ 8888888ai <br />