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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m a o <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 n j <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. m o <br /> _TSL n> n*LaL Millie APS _ a � F <br /> OWNER (Please Print) :E <br /> eA ant <br /> r5n <br /> Addre s Address 1 T <br /> City, State,Zip City,-State, Zip Cod <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) q <br /> n G) <br /> Permits) Applied for: o �- <br /> Dwelling Addition Filling/Grading Camping Unit B <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° $ <br /> Garage <br /> Structure Use: r <br /> (family home/cabin, garage, addition, etc.) 0 <br /> � <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). O <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- it within 1000 ft. and the location of any river or stream- if within if P m <br /> 300 ft. an Z v <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. m <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 <br /> dated by the owner. m . <br /> W <br /> PLOT PLAN <br /> h (2� <br /> 111 m <br /> Vo <br /> n <br /> 0 <br /> m <br /> v � <br /> w <br /> z <br /> a <br /> F <br /> A o c m .a y 9 <br /> 0. DK'� saw a = M <br /> '^ "< Ur . Q 00 010' 3 <br /> Z of mQ <br /> P qE T t_n 9 <br /> U G) E O <br /> g ' ice ' C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best ofmy knowl- c m "`� i m <br /> 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- w m w D <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. I g 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. T 3 g m <br /> N al O <br /> SIGN HERE I a <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR g E <br /> TOWNSHIP PERMITS MAY BE REQUIRED R N 8f N w H N Inoo9 m <br /> ggggggggy <br />