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r , <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d � o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the A m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and n <br /> regu�la�ti ns of he StateWisconsin. d <br /> x /Ziff r��A� a = o <br /> OWNERPlea Pri <br /> / 32 wok 4 s /u S C°1rnr a°Y�O uN O G✓g�m/� , <br /> Addr s k, - S3Y 3 Add ess <br /> City, StAte, Zip code City,State�ip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name ® 11 A \ <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s) Applied for o o `� <br /> Dwelling Addition Filling/Grading Camping Unit S 3 <br /> v <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: v< e� G r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> T <br /> DIRECTIONS FOR PLOT PLAN DRAWING: A ro <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 (OF). 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 o c <br /> 300 ft. an z c <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. m vt�l <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I 1`, <br /> dated by the owner. 1A ` , o�4 <br /> PLOT PLAN <br /> Q P <br /> a <br /> 3 N m <br /> m <br /> l � � <br /> � Z <br /> � t <br /> &a f <br /> a <br /> Nl <br /> VI m O c m o n m <br /> Dai 'RK k2 M <br /> a m < cw3, .03 <br /> ? T� � <br /> 2 m <br /> I declare that this application(including any accom nying schedule)h been examined by mea he best of my knowl- S '^ m <br /> m <br /> edge and belief it is true,correct and complete.I acknowledge that I am r onsible for the detail and curacy of all informs- w m w E O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I r�6pgnize that this infor- [ `b' 3 N [ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining wheth�er to issue a permit. I <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 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 reasonable time for the purpose of inspection. <br /> m <br /> A m A N <br /> SIGN HERE <br /> (s,gnat ofown orbuilding contractor) (date) <br /> o : <br /> ZONING ADMINISTRATOR <br /> w <br /> N NOfJ 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N 8 O 8 m O O m <br /> 8 $ $ 8 $ $88umi <br />