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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw m o 0 <br /> APPLICATION FOR — LAND USE — PERMITSd 3. <br /> a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <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. o <br /> C <br /> 6 <br /> E <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> idaw s <br /> 1c sePrinc <br /> Address Address i <br /> z 94q 17 -2 0r r'l V' <br /> City, State, Zip Code City, State,Zip Code h <br /> 45j a' 1�; Sel ?7L �r <br /> Telephone 6 Telephone <br /> i�9 - i4�F' <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o ` <br /> Permit(s)Applied for: o o <br /> m r , <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> v <br /> z a <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage c <br /> Structure Use: <br /> 0 <br /> (family home/cabin, garage, addition, etc.) Mill <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X O <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (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 ? <br /> 300 ft. z <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building o <br /> to lake, river or stream, if applicable. M 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C r <br /> dated by the owner. w <br /> M <br /> PLOT PLAN <br /> � C <br /> 3 c ad l�rwi n - <br /> 'J J <br /> OQ <br /> o IRS <br /> m <br /> °Q <br /> o <br /> N <br /> ` 2 <br /> C <br /> p NU) 17mr DD p <br /> MM <br /> �. 31 6� a•'d H m. M <br /> < w O 0 t0 <br /> P f .0 Tom . <br /> _ rn m <br /> I" moo [ O <br /> [ m 2 [ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- v S m '�: m <br /> 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- <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. 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have v, <br /> access to the above described premises at any reasonable time for the purpose of inspection. [ w 8 0 <br /> 3 A N <br /> SIGN HERE / Z�10 <br /> (signs ure of owner or building contractor) (date) '. <br /> o : a : <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED y00 0008m <br /> 888gg8g8vi <br />