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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v o ' O ' <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 y <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirementsof 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. <br /> y1 � y o <br /> DclVI. f :J5Tenn\I / � �-CA nn no VI,(/ / r //f/) CC(AVIt'-1 a ` O <br /> OyyN�c(P2lease PYe> <br /> Contractor or Surveyor or Agent o (/t <br /> �/ ; l m_ <br /> r <br /> A dress Address I \ <br /> City, State,Zip C e City,State,zi Code c <br /> Telephone Telehon-e � 1 ) QL <br /> N (off' fyepjd <br /> Emergency/Fire No. and Road Name CC77 <br /> n <br /> Legal Description.(as indicated on tax statement) ,(d f 9 Q - p 1,(j i✓r'S rD n off' �-�'I e o 0i <br /> 5eC a8 Twp yi, Ramage Ile y G <br /> Permit(s) Applied for: 0 <br /> Dwelling ✓ Addition Filling/Grading Camping Unit o = <br /> z <br /> T <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage .—. <br /> Structure Use: ��V✓1 I kc)n <br /> (family home/c bin, garage, addition, etc.) <br /> o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: O <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). <br /> 00 <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 v <br /> 300 ft. 71 z `o <br /> 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 <br /> to lake, river or stream, if applicable. 111 0 <br /> 5. J <br /> ,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and I: <br /> dated by the owner. m \ <br /> PLOT PLAN <br /> ) c <br /> 0 <br /> J <br /> N \ x) <br /> O <br /> J <br /> O <br /> O r <br /> N_ <br /> n �1 <br /> z <br /> nN N . C O ,O u 0 <br /> V(�/(�� ) N <br /> !V Z ry <br /> N Doi ID <br /> g : <br /> w c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 mm <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- d, m d, p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- o 'm <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- d, <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ro <br /> access to the above described premises at any reasonable time for the purpose of inspection. m No <br /> m 3 8 0 <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) [ <br /> P�ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N o N �" <br /> pN OpI pN pN pO pO <br /> 8 0 0 0 0 0 S <br />