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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> u o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <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 of the State of Wisconsin. y m <br /> f�f A N "I"' /✓ r d A e O ? w 4 17 I/ O N I cl Y < 1. /✓ n <br /> OWNER (Please Print) Contractor or Surveyor or Agent v <br /> Address Address <br /> Cit State, Zip Code City, State, Zip Code I <br /> I � v10 r csR d foci 42 6,-wY C. S`f943 o gJ <br /> Telephonef Telephone <br /> G6- 33 73 6S6 - a� YY <br /> Emergency/Fire No. and Road Name <br /> r',-,.v. `c G 0 J 0 .Iw-`ss 7 <br /> Legal Description (as indicated on tax statement) <br /> n G> <br /> 0 <br /> Permits) Applied for: 0 <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° g <br /> v <br /> Z o <br /> Accessory Building —� Sanitary Privy Subdivision o a <br /> Garage <br /> Structure Use: A rd y e of `! .2- r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <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 o <br /> 300 ft. o n �j <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 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 <br /> dated by the owner. m 6 <br /> PLOT PLAN ISL <br /> N <br /> U I � <br /> o <br /> v <br /> v ' 1 n IS Z <br /> dII..11.¢� c '3� f <br /> , <br /> 10 1W <br /> ,"° <br /> ,�4 v <br /> ; -oFUJHy x <br /> oc � mio <br /> V <br /> oan' <br /> m <br /> _ O .r y 9d� m} C . 0 <br /> 000 IL L0 o - � m0Z? <br /> _ Qu <br /> .-lam— m <br /> Q <br /> * At ut, I: rvfgt Me- `0 O <br /> 8i O. . <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o_ : m j� m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- v 75 'm [ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 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 ,�„ <br /> o o ; <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> A w <br /> O <br /> m <br /> SIGN HERE 4o� ( a roof owneror ng contractor) (date) Y' <br /> ZONING ADMINISTRATOR �/' �'r �C� I ' f q�1 a g <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N N N O O O m <br /> $$ 8 $ 8888y <br />