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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 H <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 3 a <br /> regulations offt�the <br /> eS^State <br /> [off isconsin. m d <br /> 6i�51e, /—+C7hCT iUD a O <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> Q8 <br /> 141,7* <br /> 7" Aa so m <br /> Address ( <br /> City, State, ip Code Yv City,State,Zip Code <br /> iia 1aa - 9o5a <br /> Telepho Telephone - <br /> �5o�f3 <br /> Emer ency/Fire No. and Road Name <br /> g ��S / 7 �1� Q�lil� 7 <br /> Legal Description (as Indicated on tax statement) <br /> A L <br /> O <br /> Permit(s) Applied for: 0 Q� <br /> w , <br /> Dwelling Addition Y� Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P } <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) _. <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 4- <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 Do <br /> 2. Show the location of the well (W),septic tank (ST),and drainfteld (DF). 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 an <br /> P <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 <br /> to lake, river or stream, if applicable. <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C Q <br /> dated by the owner. 111111m <br /> PLOT PLAN I F <br /> �F.PTf L �r <br /> fJK <br /> � s <br /> UJEiL % X o <br /> X <br /> o <br /> m <br /> w <br /> ;7 <br /> y moc � mmoa m <br /> �. Dai ' <br /> + See Uur 3¢4 �r _ U-2: <br /> N 0 <br /> O O TN : : a <br /> M <br /> C <br /> 1�. c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ^g '° m I m <br /> 0 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- yy!! Ci <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 relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 [ 8 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 O o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> T 3 n <br /> Ain <br /> SIGN HERE N m 8 <br /> (sig re f ow orb 'Id' g con ractor) )! } -E= �(�iae►ri <br /> ZONING ADMINISTRATOR 8 <br /> Hd,�=wwww T <br /> APR 7 N � NNi oo � m <br /> TOWNSHIP PERMITS MAY BE REQUIRED B �� <br /> ' i 88888888rmn <br />