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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C W a o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <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 a <br /> regulations of the State of Wisconsin. m ° <br /> ljhe4j50// 14 1A a f <br /> OWNpER (Please Print) / Contractor or Surveyor or Agent o <br /> c") S Z "S N rJ <br /> Atl ess S Address <br /> City, State, Zips City, State, Zip Code � ) <br /> Telephone Telephone <br /> 7s6 - � �76 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n O LJ <br /> Permit(s) Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v \ <br /> Z ii Ir <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: o <br /> (family hom /cabin, garage, a ition, etc.) " <br /> � 1 <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 drainfiaid (DF). 3 <br /> an 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. o n <br /> 4. Show dimensions in feet ofthefollowing:(a) building to all lot lines,(b)building to center line of road,(c)building m <br /> to lake, river or stream, if applicable. Ly <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and a <br /> dated by the owner. M <br /> PLOT PLAN V 0 ,6 SSS A- KL � I <br /> ? Ocil <br /> /44 <br /> N <br /> m <br /> n <br /> . o <br /> O <br /> Zy i 0� m <br /> h � O <br /> N D <br /> `") n oc � mm �n� m <br /> m ' ° m <br /> JJ n� ma0 } _ 3 <br /> Z <N m m i <br /> 2 : m <br /> $ p c C <br /> I declare that this application(incl ing any accompanying schedule)has been examined by me and to the best of my knowl- o 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 informs- w m to o <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I E $ 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 so- N [ <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. w $ m <br /> m A m <br /> SIGN HERE <br /> (signature of owq@r or buildin tracto - ate) It <br /> ZONING ADMINISTRATOR { It <br /> TO NSHIP PERMITS MAY BE REOUIRE� ''t, C� �?1 u 8 o 0 0 8 r't+t <br /> sss8s $s9vi <br /> m <br />