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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m 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 m 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 m <br /> 0 &W�� FF 11� Cz a W �- <br /> OW � Contractor or Surveyor or Agent 'ev <br /> AddE�s ` a7 <br /> , $t �r, IIn Address V <br /> City{, areeZZip�CJlod r l City, State, Zip Code i <br /> I elepho �^ Telephone ' <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n Q <br /> Permit(s)Applied for: 0 C. <br /> m r <br /> Dwelling 'X_ Addition Filling/Grading Camping Unit E o <br /> Z vo <br /> Accessory Building Sanitary Privy Subdivision o m <br /> Garage <br /> Structure Use: / H )1) `'w A 1I'V r+ 4 Saa I + S Jt e-z 1 <br /> (family home/cabin, garage, ddition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 9 0 <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfield (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 on <br /> o c <br /> 300 ft. o n <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m ' y <br /> to lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and CC <br /> dated by the owner. a, n <br /> PLOT PLAN rnrn <br /> I f " <br /> TC14 c H69 <br /> I N <br /> o <br /> c � <br /> w <br /> Z <br /> � 9 <br /> r <br /> O O. g � <br /> a _ a m a 0 9 <br /> byil-/ ov�9rade. a 0 < . 2 WC H o D 3 <br /> S71a <. N i � ZQ : <br /> 3/.S X 41(7" .0 � ' N m <br /> aa' c) ID <br /> C <br /> g ma <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- [ O. m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all inforrna- g� m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i15 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 0. ig 8 <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 010 <br /> access to the above described premises at any reasonable time for the purpose of inspection. a g , <br /> m i V A w <br /> m m a <br /> a in g : <br /> SIGN HERE <br /> (sig ature of owner or uilding contractor) (dat ' <br /> o : <br /> ZONING ADMINISTRATOR r g <br /> TOWNSHIP PERMITS MAY BE REQUIR un <br /> o d m <br /> 8 $ ai <br />