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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m W o 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 v N o <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 a <br /> regulations oftheState of Wisconsin. <br /> OvyNER {Pease Print) �-(�y z Contractor or Surveyor or Agent o <br /> /.ur/Lr �i..�t mo o. /¢y`r. r�69f �(re. 2r <br /> Address Address <br /> Lc. s T. <br /> City, State,Zip Code City,State,Zip Code 1 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> n L) <br /> Permit(s) Applied for: ve�� o 0 <br /> Dwelling Addition Filling/Grading Camping Unit R O^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: Z49,1-j;1//Siyt Dff, / _✓ 1,0 ' X dL A';2f ` <br /> o <br /> (family home/cabin, garage, addition, etc.) <br /> Mill <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). n <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (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 v <br /> 300 ft. o n t <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, If applicable. in O <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. <br /> PLOT PLAN <br /> 9 75 <br /> fir ' <br /> EV w, <br /> N N <br /> O 1 <br /> J V <br /> m - <br /> tX � Cjec�- <br /> a� uN,t y7TJ <br /> 3 <br /> fb <br /> I '^^'� D � <br /> Q //.j�' L Plot rM oc � mm cDiagV <br /> 9 a 15. : `Z N O J ,p <br /> a <br /> 7w = 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- o `; In <br /> In <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <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. I 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 u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. ' m 8 m <br /> m 3 n m <br /> SIGN HERE /ZY <br /> jr *1�9 e of owner ,o building contractor) (date) v <br /> •�: o : ? : <br /> ZONING ADMINISTRATOR <br /> N N O N M <br /> TOWNSHIP PERMITS MAY BE REQUIRED I p u 'o m <br /> 98899 $ in <br />