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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Adroinistrator d 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS = 3 <br /> TO <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and a ° <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the require ants 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 of the State of Wisconsin. 1 H e <br /> 1�1�NTo2 t/a HrJ St) A y <br /> OWNER Please Print n O <br /> ( ) Contractor or Surveyor or Agent o > <br /> J <br /> Address Address <br /> City, State,Zip Code City, State,Zip Code ! <br /> C6/a> <br /> Telephone —�-� Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal ascription (as Indicated on tax statement) CD <br /> o ` <br /> Permit(s)Applied for: o c P\ <br /> < _ <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit c ° <br /> v <br /> Accessory Building _ Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: �i9�ia <br /> (family home/cabin, garage,addition, etc.) 2 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 e <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X n N <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 .1 F ( N <br /> 300 ft. z W c <br /> � o 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 n p , <br /> to lake, river or stream, if applicable. 111 `Kf\X o <br /> J <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 /> PLOT PLAN <br /> Cr <br /> I � " <br /> O <br /> v. <br /> S _P7- <br /> ` t` <br /> �ti y � T9ir/c ry <br /> — ,c;�p z <br /> - �o <br /> DD <br /> m2.0' ;DW 03. Anab m aN � =' 3 <br /> N O J <br /> 03 N <br /> m <br /> € m 2 € C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the beat of my know,- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- O <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize hat this infor- $ m N <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to isA ue a permit. I ? g m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am provi Ing in this ap- a <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized Jerson to have CA <br /> access to the above described premises at any reasonable time for the purpose of Inspection. ' a g m <br /> 3 A n <br /> SIGN HERE Q Z //�l° / L <br /> ( ' na ne <br /> re of o r r wilding contractor) (date) <br /> ZONING ADMINISTRATO g <br /> TOWNSHIP PERMITS MAY BE REQUIRED a a`j ««a n <br /> ri .cNiic"'nN�n889m <br /> ggggggggN <br />