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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 64872 Office of Zoning Administrator ; 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 £ <br /> 70 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 „ y✓ <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinanc s and the laws and �. o <br /> regulations of the State ofWisconsin,i <br /> A �� t d <br /> bWNFRlease Print) Contractor or Surveyor or Agent o <br /> ddress Address <br /> DiiItJ�C,k' y 14rsP,' - ,� j,l Q- . <br /> City,State, Zip Code _ City,LSt e,Zip Code <br /> Telephone Telephone t <br /> Emergency/Fire No. and Road Name <br /> syn /)-) 14/A',!1) 44 4C-IRVAL) <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s)Applied for: o. o <br /> J <br /> Dwelling . ....-.-._ AdditionFillingJGrading Camping Unit o <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Structure USe: �ll./1 d.Q.,f'/ <br /> (family home/cabin, garage,4clition, etc.) ° <br /> 1A <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). 2 <br /> 2. Show the location of the well (W),septic tank (ST),and draiMield (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 10 v o, <br /> 300 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 0 'o <br /> 5. <br /> to lake, river or stream, If applicable. III p� a <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C Y <br /> dated by the owner. m <br /> PLOT PLAN <br /> � I i <br /> f I C <br /> m <br /> n <br /> N <br /> O <br /> J <br /> m <br /> D � <br /> >/ov' <br /> W C W r nE 9 <br /> 33 JJoa m <br /> e, 0 a c: y <br /> Z <@.w' : Z � o �m3 <br /> O Y 8Yl i i T N i i S fin : ZE Q <br /> m c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. (y�J g 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- ' yg!!m ' 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 Burnell Wisconsin in determining whether to Issue a permit. ; 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 ut <br /> access to the above scribed premises at any reasonable time for the purpose of inspection. m g,g <br /> g v A w <br /> SIGN HER <br /> W: N <br /> (signet of owner or building con rector) (date) <br /> ZONING ADMINISTRATOR �• u.O1�Y(1 S i <br /> TOWNSHIP PERMITS MAY BE REQUIREDm <br /> utN vl ,�n cnoo m <br />