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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M-- 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Z m <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 applicabJCounty Ordinances and the laws and 3 n t^ <br /> regulations of the <br /> e State of Wisconsin. w iu o <br /> 0 . R(lease Prim o a d y r or en o <br /> 9� t� � <br /> dere sAddress I <br /> City, State, Zi Cod City, State, Zip Code C� <br /> Telephone Telephone c7� <br /> 7 r✓�-_ SD 1. ?. <br /> Emergency/Fire No. and Rf'}d Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s) Applied for: o ° <br /> J <br /> Dwelling Addition Filling/Grading Camping Unit 6 � <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage // <br /> Structure Use: ��_Irr/q 9P, Cly%1� i2)l K7 4 P_ � � d �Q�4Dc)r7') Y <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). <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 <br /> 300 ft. Zv <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 o a <br /> to lake, river or stream, if applicable. mS130 M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I 1 <br /> dated by the owner. m <br /> PLOT PLAN <br /> C�) <br /> I <br /> 0 <br /> c > <br /> h <br /> 1 / 7 <br /> nom - IIC 0'7� � <br /> vlP r /Ltt <br /> none > � oao � <br /> m <br /> .1r <br /> O- o_ <br /> mgN <br /> O 0= 0 3 <br /> Z 5 m <br /> J 21 M <br /> 7 _ � : m <br /> ID <br /> C <br /> I declare that this application(including - p anying schedule)has been examined by me and to the best of my knowl- 3 m `� M <br /> edge and belief it is true,correct and compierd.I acknowledge that I am responsible for the detail and accuracy of all informs- — d, m mO <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 <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 <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 des ribed p"es es at any reasonable time for the purpose of inspection. m 8 m <br /> N 3 A N <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) o x <br /> ZONING ADMINISTRATOR8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N N O O O m <br /> 888888880 <br />