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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator IN <br /> (n -10 o / o <br /> 2. <br /> APPLICATION FOR — LAND USE — PERMITS d - <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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 n <br /> regulations of the State of Wisconsin. H m <br /> 4 �� N^mW N d r Up <br /> OWNER�, ro�(Please Prim Contractor or Surveyor or Agent o o m <br /> 3a7i eryr � L, d <br /> Address Address <br /> I-pi %jvrsM1avv ,e173 . My, SJ'C'716 <br /> Cit State,Zip C de City,State,Zip Code ) <br /> Gra - S s <br /> Telephone Telephone i � O <br /> Emergency/Fire No, and Road Name �� V i <br /> Legal Description (as Indicated on tax statement) y" <br /> Permit(s)Applied for: o ° g <br /> J <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: <br /> (family home/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 r LV <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. 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 A t y <br /> to lake, river or stream, if applicable. m e o <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. 0 <br /> PLOT PLAN q I� <br /> SU f' <br /> e <br /> n_ <br /> 0 <br /> J <br /> N fn <br /> O 1 <br /> J <br /> J <br /> m <br /> O � � <br /> /Iv � <br /> -00 <br /> A o c 2. m m o a : m <br /> - a� '--� am ai9 a <br /> O < `C N O J J _� <br /> Z N <br /> M <br /> – m <br /> S G) [ D <br /> UI d c C <br /> 8 = ! m 3 € a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- : S : 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- (n m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- _`b' d N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m 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 havec, <br /> 0 . <br /> access to the above described premises at any reasonable time for the purpose of inspection. � m 8 0 <br /> m i 3 0 <br /> N V A N <br /> m a <br /> SIGN HERE—P '1-ay- 90 ~ H gi <br /> If (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR `� tS r�'y 16A1�� g <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> NNN u, 00 `� m <br /> 889 BgggN <br />