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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v --o <br /> APPLICATION FOR — LAND USE — PERMITS 3.TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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 <br /> regulations of the State of consin. y <br /> 6'A � y <br /> lf']rtflAE a o <br /> OWNER Please Prip� ., Contractor or Surveyor or Agent <br /> /�� 7 .7's <br /> AdtlremssA <br /> Address <br /> City,State,Zip Code City, State,Zip Code <br /> l <br /> Tel hone Telephone <br /> R S-3 / 7-11eMP%V AA v RX AJ <br /> Emergency/Fire No. and Road Name ) <br /> Legal Description (as indicated on tax statement) <br /> n G) <br /> Permit(s) Applied for: o �. <br /> Dwelling Addition Filling/Grading Camping Unit °^ Z <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> (family ho a/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <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). C 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 P <br /> 300 ft. 0 ) 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 t7 y <br /> to lake, river or stream, if applicable. m C <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. m <br /> PLOT PLAN <br /> © rFR <br /> 0 <br /> m <br /> N <br /> z <br /> n. <br /> Q Z <br /> t <br /> ' N <br /> w <br /> r o c ! '.n v n p, m <br /> 9 <br /> DO H <br /> m o D in 3 <br /> N <br /> Z <br /> o ry � N ,� 1 <br /> f T N In <br /> N i g <br /> C <br /> n i <br /> g ac ' C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ! o ; a <br /> 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 relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 A 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- N <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 res nable time for the purpose of inspection. 1` i w g <br /> N V A N <br /> SIGN HERE 4 1 N g <br /> (signs r wner orontractor) (date) o x <br /> ZONING ADMINISTRATOR g <br /> d1 � Mf_H Wo_fHT <br /> TOWNSHIP PERMIT AY BE REQUIRED o 8 m <br /> 888vi <br />