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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 01, IM0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y �1 <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 3 0 <br /> regulations of the State of Wisconsin. 0 o <br /> GQ/P/4 N,9 X,lM TO•"/ A55,MR 0�"•y <br /> N <br /> n O <br /> F <br /> OWNER (Please Print) Contractor or Surveyor or Agent <br /> m <br /> m <br /> Address Address <br /> 7s a s- 5IVArt&- Ro do• RD A <br /> City, State, Zip Code Tom( State,Zip Code <br /> SC 6777' ro w.tN 5-/t/:a BU,P.bE'T/-Co S e c 77- N-- <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o °- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit 0 ° Qj <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <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). 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 ? c <br /> 300 ft. an Z $ <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 b�,�,1 y <br /> to lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. m , <br /> PLOT PLAN <br /> m <br /> v I I 0 <br /> o <br /> 0 <br /> � m <br /> �I o <br /> T�SAN rC f <br /> on c m a m <br /> - P� ' o. m am <br /> Hoi <br /> ma ' z � 3 <br /> ZAo € Cz : 1 <br /> P f T n M <br /> -- <br /> a m <br /> g c . <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe detail and accuracy of all informs- w m N 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 Burnett Wisconsin in determining whether to issue a permit. 1 8 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 n "' o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m g m <br /> In 3 0 : <br /> H u 8 <br /> SIGN HERE / <br /> (signature of owner or building contractor) ( ate) o s <br /> ZONING ADMINISTRATOR g <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> ggg888ggN <br />