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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 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 m o <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 a <br /> regulations of the State of Wisconsin. <br /> rr4 . l ur�fPtis a <br /> F <br /> / R�(Please <br /> ?fie n r Contractor or Surveyor or Agent o <br /> Add ess XR K d Address <br /> UVKS YMK Ss337 <br /> Cit State, ip Code City, State,Zip Code <br /> 60P q3a -7 3zs- <br /> Tel4phone TSlephone <br /> 3o�341 W ids PAL?4*P& �d s, <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> c o <br /> Permit(s) Applied for: 0 <br /> m r <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary _ Privy Subdivision ° z <br /> Garage <br /> Structure Use: r <br /> 0 <br /> amity ho /cabi rage, 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). M 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 1 v Ch <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 t w <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, m <br /> PLOT PLAN yJ��''�ar, 4*22 r <br /> I <br /> 11 <br /> k m <br /> m <br /> 1 0 <br /> o <br /> N <br /> m <br /> w <br /> Z <br /> 9 <br /> 1 <br /> 11 <br /> o c 2 m m o n F Mo <br /> m <br /> M <br /> a m < m C m O 3 <br /> N O 30 <br /> f J ZQ i <br /> m <br /> C <br /> M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c 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 informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E 25 ro N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 r ri i i8 m 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the bove described premises at any reasonable time for the purpose of inspection. <br /> T 3 O A . <br /> m v w <br /> m : A <br /> SIGN HERE <br /> -/s- 9r H N <br /> (sign tuTof o �b^uild1ing � <br /> ontr tor) (date) �y c V [ <br /> ZONING ADMINISTRATOR "� ` L�f-t1,ll��� �! � g <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> X888 ' <br />