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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the io <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and __ n <br /> regulations of the State of Wisconsin. m m <br /> l ob'77 IC 7AXL,S 0A1 a <br /> OAR (Please Print) Contractor or Surveyor or Agent o <br /> dress Address f <br /> eat! /. it/cEN:TTK /4"'/1/ :L Sy30 <br /> City, State, Zip Code City,State,Zip Code <br /> C t2- 5-CI-2-d0 <br /> Telephone ' Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> � o <br /> Permit0s) Applied for: 0 <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit o' <br /> v <br /> Z 'o <br /> Accessory Buildin 12� _ Sanitary Privy Subdivision ° m <br /> Garage n �( /l <7 <br /> Structure Use: w x �y \3 6dot <br /> i <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <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). 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. o <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. <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. 40 M N <br /> PLOT PLAN v <br /> I <br /> O <br /> mOUiShE'o, pror <br /> / m <br /> w` <br /> IL <br /> Z <br /> w , � m <br /> MwECo. L1 f. <br /> <: � uCio � m' 3 <br /> Ems ; Tc' M <br /> cC : m <br /> o <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- : c 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- <br /> 'c H m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 3 ut E <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g e 8 <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 n N o <br /> access to the above de ribed premises at any reasonable time for the purpose of inspection. $ 8 <br /> 3 $ <br /> Gy 3 Aw : <br /> SIGN HERE <br /> a : <br /> (signature owner or building contractor) (date) <br /> ZONING A INISTRATOR �l rn ' 4INl6 AIA-) g <br /> TOWNSHIP PERMITS MAY BE REQUIRED N k89999199UM) <br />