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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator t � o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m U <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � y o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of 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. o <br /> o <br /> m <br /> n <br /> WnNER (Pleaass}e-Pyfint) �y�/ Contractor or Surveyor or Agent o <br /> o Address <br /> SON " m m <br /> Address Address <br /> 1A/r <br /> City, State,Zip Code City,State,Zip Code <br /> Tele( NSe <br /> rr et nn F' GI�S� ` Telephone <br /> Emery/Fire No. and Road Name l <br /> Legal Description (as indicated on tax statement) v <br /> Permit(s)Applied for: ^' o <br /> o C. <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Accessory Building _ Sanitary Privy Subdivision o 0 <br /> Garage mi <br /> � 1 <br /> Structure Use: rr <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <br /> Mill <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). M O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 0 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 3 u + <br /> 300 ft. 11 2 c <br /> � o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 0 s <br /> to lake, river or stream, if applicable. o <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 <br /> u! <br /> ' n <br /> 0 <br /> 1vie <br /> �Q,( GtiC•� �l y. s o �`� <br /> qq m <br /> ti(4 <br /> O t Q Aj P �✓ � v r.r <br /> �l r e)Cr <br /> o�� <br /> S r s I 9 <br /> f <br /> y <br /> 1 ���` ]7 UlN V fOrDDp 17 <br /> _ ..� oc =. mm naE RI <br /> 151 00 <br /> 0 „ N: m <br /> L" c g : i ID <br /> g n <br /> S <br /> I declare that this application(including any ac ompanying sche u fined by m and to the best of my knowl- o : m ',: m <br /> edge and belief it is true,correct and complete. acknowled a the, I am res nsi a for the det it and accurac of all informs- m <br /> 9 P 9 Po y to m vi '. O <br /> hat I recognize that this infor- $ m N <br /> mationl am providing will be relied upon by the County o urn tt iscbnsin in determinin whether to issue a permit. I 8 m 8 <br /> further accept all liability which may be a result of the County of B men relying on this information I am providing in this ap- <br /> plication. I agree to permit county officials charged with administe ing county ordinances or other authorized person to have a aN <br /> access to the above scribed premises at any reasonable time lot the purpose of inspection. m a [ <br /> m 3 A o <br /> A N A <br /> SIGN HERE <br /> 8 <br /> n� <br /> Isre of own building contractor) (date) n <br /> S(J <br /> ZONING ADMINISTRATOR -" ) 8 <br /> TOWNSHIPERMITS MAY BE REOUIRED N O N^w ^ T <br /> N NU, NOO � m <br /> 88888988ai <br />