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n ' 'r <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 M a o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m m <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown therein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regull o,nnsyof the State of Wisconsin. y <br /> (�(.Gl� <br /> OWN 11 Please P 'n) Contractor or Surveyor or Agent o <br /> Addess/�/ / Address <br /> City, Sta}� Zii Code (( City,State,Zip Code I <br /> X ' <br /> Telephonee 717Z Telephone <br /> I <br /> Emergent /Fire o a d Roan mg- <br /> Legal <br /> Legal Description (as indicated on tax statement) <br /> 0 <br /> 0 <br /> Permit(s)Applied for: 0 <br /> r � <br /> Dwelling Addition Filling/Grading Camping Unit ° g <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision P } <br /> Garage <br /> Structure Use: r <br /> 0 <br /> (f mily home/In, garage, ad ion, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M <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). C 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 ilt <br /> 300 ft. 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 <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 Gy .) r 41 <br /> dated by the owner. m <br /> PLOT PLAN <br /> C) <br /> 1. n <br /> v"\ J <br /> o <br /> I, , J P <br /> U <br /> 1 <br /> \� I z <br /> 27- <br /> m o c m m o a t <br /> `c m <br /> �. Da'� anw nM <br /> N ,p <br /> a m — 3 <br /> G H' `Z 2 J <br /> P F J r� M <br /> _. T : <br /> 2 O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 5.o m ig M m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- `n m w 0 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 [ g m g <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 N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 $`s <br /> m a A x <br /> is � 1� m m <br /> SIGN HERE���-, �/� � 8 <br /> (sign , re of owner or building contractor) dater <br /> ZONING ADMINISTRATOR <br /> wtw� wwwT <br /> TOWNSHIP PERMITS MAY BER QUIRED n N o o fS m <br /> �/�d <br /> 8 888 N <br /> 1a 16&7at Permit 4pla mei 1,,0(- 5-,-.j)-9/ Yy0�� <br />