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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co m -00 0 <br /> CD <br /> APPLICATION FOR — LAND USE — PERMITS f <br /> TO THE ZO VgegbMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> located as sown 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 _ <br /> regulations of the State of Wisconsin. y <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> Addre Address <br /> City,State, Zip Codg. V Vk'11? rco yr 15111 3City, State, Zip Code <br /> Telephone ���/ 3 S� 7 (,/ Telephone <br /> Emergency/Fire No. and Road Name <br /> AZA n 7�4e,P X 4 ,97-e Z, yLj�' <br /> Legal Description (as Indicated on tax statement) o <br /> 0 <br /> Permits)Applied for: o <br /> _ <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit 0 ° <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage /l � .� <br /> Structure Use: X �`-�� 0 °rT. <br /> (family home cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (@B) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (1M, septic tank (ST), and drainfield (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 C <br /> 300 ft. e' 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 A y <br /> to lake, river or stream, if applicable. m 3 <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 lowner. <br /> PLOT PLAN �0 RM <br /> 1 w <br /> 64 -vIdv _ <br /> oR�Ila <br /> 1 06/ <br /> m <br /> V Z <br /> io <br /> S I <br /> <.a' z ?m <br /> 8 ? Qc : G <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S '• �^ �' ? 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relled upon by the County of Burnett Wisconsin in determining whether to Issue a permit. 1 g 0 g <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. I m g <br /> Ate : <br /> N <br /> 3 - 9i H <br /> SIGN HERE <br /> 61 (signature of owner or building contractor) (date) ' v <br /> ZONING ADMINISTRATOR 17 1 I ' -?7�la1v <br /> TOWNSHIP PERMITS MAY BE REQUIRED ; c m <br /> 99999 8 N <br />