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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -10 <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 <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 a <br /> regulations of the State of Wisconsin. m <br /> \ M N <br /> OWNER (Please Print) Contractor or Surveyor or Agent <br /> m <br /> m <br /> Address Address <br /> City, State, ZodeCity,State,Zip Code <br /> / s <br /> 610 -j i'/V z <br /> Tel hone Telephone <br /> ( 61127 ss3 - 0 --a3a <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) Q <br /> o � <br /> Permit(s) Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v 1 <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage / e <br /> Structure Use: ram./v C ^ <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M n <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). G 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 pco <br /> 300 ft. an a 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 H <br /> to lake, river or stream, if applicable. M <br /> S. 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 4j k (s Oenlu(� p„� r s <br /> so <br /> 13q � <br /> m <br /> � o <br /> 1� '7r I <br /> m <br /> epr <br /> 13 <br /> VT <br /> 3�44 <br /> � � s <br /> I� 04yl <br /> L � I I I� <br /> m <br /> /� � J 21 <br /> r O 0 0 Z <br /> i///-'/dPLu /9,CPds T �6� rpuc[e..0 QcC 0 T`2$ S L✓K�" !/��� N <br /> g tried by by me and to the est of my knowl- o c i <br /> 1 declare that this application(including any accompanying schedule)has been exama m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- = ? w N! O <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 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 have u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. ' m 8 0 <br /> 'B pin <br /> SIGN HERE <br /> (sign f owner ilding con actor) (date) c x <br /> ZONING ADMINISTRA'O" g ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED u m o 0 <br /> pN O pHN <br />