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Burnett County 7410 Co. Rd. '(, No. 102, Siren, WI 54872 Office of Zoning Administrator CnM o a <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and o V <br /> located as shown 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 3 a <br /> regulations of the Sate of Wisconsin. y m <br /> fl <br /> 1%�iti u 7a wQ e1 � a �/f <br /> QWNER (PIease <br /> a /� Contractor or Surveyor or Agent o <br /> Cl r it ,/y n U m <br /> -Address Address <br /> CitZip Code City, State,Zip Code Q� y <br /> eaState,m(At., `fon+ M Ju. "5 5'eI3/ (� <br /> TelephoV QTelephone T <br /> �. (a r/au k ah// 0 e <br /> Enuency/Fireil apd oad Nano-� -T7 7� 1) 10 <br /> ,, r C <br /> /'tel rn/ (y. 1. I r See— 16, 3711, G� I"1 �t� �/QN+�J <br /> Legal Description (as Indicatfid on tax statement) o /\ <br /> n � <br /> Permit(s) Applied for: 0 °. + <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision <br /> ge <br /> Structure Use y- a''- a' o <br /> (family home/cabin, garage, dition, 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). 2 O <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 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 w <br /> to lake, river or stream, if applicable. M <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 /> //J m <br /> PLOT PLAN S e e � <br /> I <br /> � m <br /> 1 <br /> 1 O <br /> {I0 <br /> N <br /> 0 <br /> m' <br /> R � <br /> m_ n <br /> Z <br /> , 9 <br /> mogm <br /> m = a� =.am ami <br /> O OS m 3 <br /> f 0 T� <br /> rn m <br /> � R 0 <br /> 8 O E. C <br /> 1 declare that this application(including 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- h m O <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. I 8 a <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described premises at any reasonable time for the purpose of Inspection. 8 <br /> � n <br /> I � / : M $ w 8 <br /> SIGN HERE1 'L w w <br /> (sig u e of 0v� building contractor) (date) o ; <br /> ZONING ADMINISTRATOR ': 8 [ E <br /> TOWNSHIP PERMITS MAY BE REQUIRED S N N N N o o N$ m <br /> 8 $ 8888 $ 8m <br />