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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator u) v z <br /> u) CD E o <br /> APPLICATION FOR — LAND USE — PERMITS 3 _ <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <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 n <br /> ��regulations of the State of <br /> Wisconsin. o <br /> Y�1�jJ�M R Mr �Gh C/� m O <br /> OWNER Please Print n <br /> C k (,2 7 1 ) Contractor or Surveyor or Agent m <br /> Address Address <br /> Nbr" A Qpunc�i 119Jnn SOS b <br /> ty,Stat)Zip Code City, State,Zip Code — <br /> dl� 1e7 �l- 7b 9 � <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name iJ <br /> Seo-ttTWp a831y Dh r�., <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s)Applied for: o` <br /> o <br /> _ <br /> C. <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> AcceGara euildin ✓, Sanitary Privy Subdivision ° <br /> g � 2g6� <br /> Structure Use: <br /> r <br /> (family home/cabin, garage, addition, etc.) ° <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 9 <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings (NB) and Indicate North (N). <br /> o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). Q 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 /> 71 3 v <br /> 900 ft. Z Q <br /> 4. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building �.o S. <br /> to lake, river or stream, If applicable. – ill o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C t = <br /> dated by the owner. 1 (g <br /> PLOT PLAN lilt <br /> �._ CC 3 b <br /> N6 <br /> �r y ' <br /> cn <br /> 0 <br /> ® E8 = <br /> _ <br /> I <br /> 1 J <br /> m Z <br /> m mmvmrnnV m <br /> ". 9a� M <br /> I < � ' Z H o � m <br /> Z A o' : m .d : 1 <br /> In <br /> NN [ n n i 0 <br /> 8 : C <br /> I declare that this application(including It ompanying schedule)has been examined by me and to the best of my knowl- 6 '� ` M <br /> edge and belief it is true,correct and com .I acknowledge that I am responsible for the detail and accuracy of all informs- O <br /> tion contained in this application(including. nv accompanying schedule)and I further declare that I recognize that this g m N <br /> infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <br /> further accept all liability whidi may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication.I agree ta_permit county officials charged with administering county ordinances or other authorized person to have v, <br /> access to the above described premises at any reasonable time for the purpose of Inspection. <br /> SIGN HERE " "��CXiI,�yV` I\ r / `n : 8 : <br /> (signature of owner or buil ' g contractor) (date) :, ': n ' ` <br /> ZONING ADMINISTRATOR I ) :) `:. 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> N Ntl"tli 000 m <br /> 888888 $ rmn <br />