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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d T 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 N <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the N <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. <br /> _ N V <br /> / C <br /> LR!'7a £ <br /> 11 R Please Print) Contractor or_'ury, y, r or Agent o - <br /> /a (Nd,S� lS �l lw; rpi:ns � <br /> Addy/$ l�v�z Ad tl ass <br /> tv <br /> City,6 � <br /> State, Zip Code Ci State,/S Zip Code (b <br /> / 2 y 39 <br /> Telephone p Telephone✓ <br /> 6ot// ✓pitC Z .re 'e <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> 0 t7 <br /> Permit(s)Applied for: o °- <br /> ON COMPUTE <br /> Dwelling Addition Filling/Grading Camping �Q a ° <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage c <br /> Structure Use: a 20 1< 2 z- q s 6 <br /> (family home/cabin, age, addition, etc.) <br /> r' <br /> DIRECTIONS FOR PLOT PLAN DRAWING: Q <br /> '---��— <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). Q3 <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within q p c <br /> 300 ft. an Z v <br /> 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 n <br /> to lake, river or stream, if applicable. m 0 <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. <br /> PLOT PLAN <br /> lU �N Xly l <br /> ` ,� co <br /> n <br /> 7S' ,, N <br /> 3 �. <br /> A � m <br /> �6re <br /> ap�� or <br /> at z <br /> o <br /> i m o c m o a F rmrl <br /> I o n <br /> a <br /> H mo0.0o3 <br /> m 1 <br /> o F [ T vm <br /> 62 1 io <br /> 8 : s mom € C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ' ; 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- w m N E O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8m u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 reasonable time for the purpose of inspection. 8 <br /> m <br /> N 8 <br /> SIGN HERE `�( Xz j' a <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR atm ' �'1vth' 1 ^� g l <br /> TOWNSHIP PERMITS MAY BE REQUIRED oN, oNi a rNn 8 8 8 m <br /> 88 $ 88 $ 88ai <br />