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Burnett County 7-410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator do 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. _ — <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m v 1 <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 <br /> regulations of the State of Wisconsin. y m <br /> N <br /> C <br /> d <br /> OWNER Please P i� Contractor or Surveyor or Agent o „ <br /> OWNER ID `51 f <br /> d <br /> Ad r ssAddress <br /> /JDr el-'-911 all- 77 <br /> City, <br /> r��i yodei53 753 City,State,Zip Code <br /> Lde (�I 1 <br /> Telephone � Telephone T <br /> Emergenc Fire rho. an Rod N e - <br /> � C»li.l�rl . ,�v/-) .-, c� <br /> egal Description (as In ii ate�tatement) <br /> Permit(s) Applied for: o' �. <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision m <br /> Garage <br /> Structure Use: <br /> (family home/cV6in, garage, a ition, 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 <br /> 2. Show the location of the well (W),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 p <br /> 300 ft. 11 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 0 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 I <br /> dated by the owner. <br /> m <br /> PLOT PLAN <br /> Z <br /> m <br /> o <br /> o � <br /> N z <br /> IIIXDv�'^'I1 <br /> I I ' <br /> m oc � mto �aF m <br /> m. pa'� aaN ama <br /> 000. 03 <br /> o : z : <br /> P rn <br /> g : a c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- l 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 informa- — w m E O <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- `b' 'm <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a permit. 1 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 u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> -n 3 n <br /> SIGN HERE /0 dw / — <br /> (signs a of owner or building c (date) c x <br /> ZONING ADMINISTRATOR " g ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> ut uNioo � m <br /> � gggN <br />