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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0. <br /> regulations of the State of Wisconsin. � H m <br /> D0 q w Z q /"O r /Q- �s a4 .s C. O4 .r'fZ n m O <br /> C• f <br /> OW IS �nt' . 3 ay�L R w e Contractor or Surveyor or Agent <br /> Address , Address <br /> / , y SII c�►� '.7s-2so - ,?tk P;h L v Rt i <br /> City, State, Zip Code r CityS, Stapte, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> n_ L7 1 <br /> Permit(s) Applied for: 0 o (4- <br /> 0 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 'o <br /> Accessory Building jo�'— Sanitary Privy Subdivision ° <br /> Garage �1 <br /> Structure Use: r 4 r't p — Sty N 4 4 e <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X O <br /> 2. Show the location of the well (W), septic tank (ST), and drainfield (DF). C 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 o 0 <br /> 300 ft. o <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 y <br /> to lake, river or stream, if applicable. r <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. m <br /> PLOT PLAN <br /> By,lrli� IV&j /lay <br /> m <br /> 0 <br /> o <br /> m <br /> o <br /> m <br /> 9 <br /> m o c m m n F m <br /> <_ m o 0 <br /> N � m' <br /> Z o m 1 <br /> O � . T N 31 <br /> — m <br /> N € moi O <br /> 8 ` m3€ a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 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 ro w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E m N E <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ 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 O P o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m $ m . <br /> m [ 3 n <br /> m : A m <br /> nn 3 /0 9 / <br /> H in 8 <br /> SIGN HERE Yw a <br /> (signyfure of owner or building con ract (du e) o x <br /> ZONING ADMINISTRATOR <br /> N N ONHHdI T <br /> TOWNSHIP PE ITS MAY BE REQUIRED u v N v o o SS m <br /> $ 888 $ 8$ $ rmif <br />