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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m ; a <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> N O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v 0- <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 a <br /> regulations of the State of Wisconsin. m d <br /> ✓'��, /� � M� /�1.�,ev kir L.' v .Jsu�rm,f! a f <br /> OWNER (Please Print) Contractor or Surveyor or <br /> � � Agent <br /> Z'efZ'�X900 G <br /> Address Addres <br /> t g-Wn ' <br /> City, tate, Zi Code City,St Zip C de �(J <br /> i. <br /> Tele <br /> phonez7 <br /> ! Ielephone <br /> Emer ency/Fre No. and Road Nam <br /> 47 c <br /> Legal Description (as indicated on tax st tement) <br /> n O <br /> Permit(s) Applied for: o 0 <br /> Dwelling Addition Filling/Grading Camping Unit B g <br /> M <br /> Z o <br /> Accessory Building Sanitary Privy <br /> 1t tC L Subdivision ° m <br /> Garage /� ,1 �T/ hfclLl171Ctirc SGTe_er(/Or !O`XA' r <br /> Structure Use: v' "'.�%�I b/!T �—✓ <br /> (family home/ca n, garage, addition, etc.) <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). Ml <br /> n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DIF). 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 on <br /> 9 <br /> 300 ft. o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building N <br /> to lake, river or stream, if applicable. mP=5 5 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and CC <br /> dated by the owner. <br /> M U <br /> PLOT PLAN <br /> � o <br /> orh I o �1 <br /> z <br /> m <br /> Im On <br /> P < � T� <br /> RoAh = ~n m <br /> m <br /> L � � `: C <br /> 8 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S N m : 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- y,m <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. 1 <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 d c b pre as at any easonable time for the purpose of inspection. 3'& _ <br /> mpg <br /> N N 8 <br /> SIGN HERE <br /> (signal re of own i ding contractor) d e) o s <br /> ZONING ADMINISTRATORr�pp .U��{ji, <br /> ✓ TOWNSHIP PERMITS MAY BE REQUIRED C.N m o o o o O m <br /> 88888888ai <br />