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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o a <br /> APPLICATION FOR - LAND USE - PERMITS 3' <br /> ° X11 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and n <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the � c m (3� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. H m <br /> T�� r :loo n r-Li a /� u /e Lr offS'aa ria r at a <br /> f <br /> NE (Please Pr' Contractor or Surveyo — t o <br /> Ado ress (/� � 9 3 dress <br /> C <br /> ep V, LCI <br /> tie, Zip ode ` City, State, Zip Code <br /> TelePhTV'V6-_ <br /> O / 8 LM,'3 <br /> 7 <br /> Emergen /Fire No. and R ad N me n <br /> �a �G . _F1YY1 <br /> Legal Description (as Indicated on tax statement) <br /> n 0 <br /> Permit(s) Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: 1�1 o <br /> (family home/cabin, garage, 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). <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. In Z <br /> 4. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)buildingto center line of road,(c)building m <br /> to lake, river or stream, if applicable. M <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 /> W <br /> PLOT PLAN <br /> I <br /> t N <br /> O <br /> 47 <br /> O N` <br /> h_ <br /> O H <br /> N <br /> Z <br /> 9 <br /> n �1 <br /> f <br /> r— � f be /o <br /> m 0 . m m nm <br /> m - K, am y am <br /> ZHii pro <br /> sin <br /> L" i 6 � : O <br /> ma x <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S I 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- <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 <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 <br /> access to the above described premises at any reasonabl 'me for the purpose of inspection. m 8 m <br /> In 3 n <br /> m v A n <br /> N N Qp <br /> SIGN HERE �' n <br /> (si ature owner r uil ntra Tor) <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMIT91MAY BE REQUIRED Nov — 91990 �, II 9900101008 m <br /> J 88888888 ( <br /> —J <br />