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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator cn d 'o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and o L <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. o <br /> N v <br /> S e'5 a a <br /> f <br /> OWNE (PIN Print) Contractor or Surveyor or Agent o <br /> m <br /> Address <br /> �AJCftS�l �.r_�.1 5rfz�`�3 <br /> City, State, Zip Code City, State,Zip Code D <br /> t <br /> Telephone Telephone <br /> 1 <br /> Emergency/Fire No. and Road Name <br /> f <br /> Legal Description (as indicated on tax statement) <br /> n L) <br /> Permit(s) Applied for: o °_ <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision 0 <br /> Garage <br /> Structure Use: o�l�iu�Qr�1y"n� r <br /> 0 <br /> (family home/cab(n, garage, ad $tion, 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). 2 0 <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfieid (DF). 0 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 <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 0 w. <br /> to lake, river or stream, if applicable. M <br /> C o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 5jdated by the owner. 0 <br /> PLOT PLAN <br /> N <br /> m <br /> 09� <br /> �L <br /> V � 0 11 <br /> m <br /> w <br /> Z <br /> D <br /> oc 0m on m <br /> < E H o > > 3 <br /> P E0 Tom " 1 <br /> _. m a <br /> cc : m <br /> L" [ ci � O <br /> g S <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S ; '^ '� : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all info rma- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 haveu, <br /> access to the above described premises at any reasonable time for the purpose of inspection. a g <br /> m 30 <br /> A N <br /> SIGN HERE ~ m <br /> (sign owner or ing contractor) (date) o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PE ITS MAY BE REQUIRED ^n . 8 . <br /> $ 8 888 (Mn <br />