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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m � -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and N <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m `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. / m m <br /> /<� <br /> 17t h �i�e �>!2d �OnJf• $ o <br /> OWN,�R (Please rint) Con actor or Surve or or Agem —{ <br /> Adtlr�s / ,y Address <br /> 11yGt Q h, //ihn . <br /> -f Doc Wei r7fry . W✓- i` !3 <br /> City, State, Zip Code City State,Zip Code" <br /> Telephone Telephone <br /> i� <br /> Emer enc /Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> m -- <br /> n <br /> Permit(s) Applied for: 0 <br /> w <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary 11-0— Privy Subdivision ° <br /> Garage <br /> Structure Use: 16 M e? o <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). O <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 <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 m <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. 40m <br /> w <br /> PLOT PLAN <br /> S e g C?- Ski <br /> I � <br /> 0 <br /> m <br /> o <br /> / y <br /> n <br /> 2 <br /> ND <br /> S rnwvmr- DDS <br /> Q <br /> Z m <br /> Ems : T - i € <br /> = m m <br /> N c C <br /> g n <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ', o [ m m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe detail and accuracy of all informs- rn m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 ro rn <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 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- <br /> access <br /> av access to the above described premises at any reasonable time for the purpose of inspection. m 8 0 <br /> m 3 <br /> p N <br /> SIGN HERE 1116Ae <br /> (sign dre of owner or building contractor) 4 ate) <br /> o : <br /> ZONING ADMINISTRATOR tml lA ` 8 <br /> 0 <br /> TOWNSHIP PERMITS MAY BE REOUIRED "u8N 0 0 m <br /> 88 88888 vi <br />