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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 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 � w <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 n <br /> regulations of the State of Wisconsin. o <br /> w m <br /> m m <br /> RAw11A,11 mss o <br /> OWNER'Please Print) / /I Contractor or Surveyor or Agent o <br /> / <br /> m <br /> Address <br /> City, State, Zip Code Cry, State,Zip Code <br /> Telephone3 �_ S Z Telephone <br /> Emergency/Fire No. and Road Name <br /> � � cpm ,> >n ,�.�1 �� 6.�. 3 a�- �-L� �3 i 9' �'�✓�� �,��� <br /> Legal Description (as indicate on tax statement) o <br /> Permit(s) 0 <br /> Applied for: o <br /> 0 <br /> _ <br /> w r <br /> Dwelling Addition Filling/Grading Camping Unit o °— <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage i <br /> Structure Use: �4 x ,;)4 <br /> r <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). M n <br /> 2. Show the location of the well (W),septic tank (ST),and drainf laid (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 a 'P m <br /> 300 ft. z cv <br /> o o <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 /> GQ w <br /> to lake, river or stream, if applicable. 111 I o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C W <br /> dated by the owner. <br /> m <br /> PLOT PLAN ^� <br /> ` m <br /> 0 <br /> 3o H 0 <br /> 27F7% <br /> — > <br /> o � <br /> f <br /> 0 <br /> nn < <br /> 60 <br /> a <br /> uCo 3 ,=0 3 <br /> Z W <br /> F T m M <br /> m <br /> U � � o <br /> .: s <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of m knowl- o m; I a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- h m w : O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- _12.v <br /> mation I am providing will be relied upon by'the County of Burnett Wisconsin in determining whether to issue a permit. 1 ; 81 <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 described premises at sly reasonable time for the purpose of inspection. m <br /> m 3 <br /> 1 Lj Q w 0 <br /> SIGN HERE a <br /> L./ Nr�Ui r'/ � / /O ? y, .. S <br /> (signature of own r or b ' Ing contra o (date) <br /> ZONING ADMINISTRATOR ""' <br /> TOW PERMITS MAY BE REQUIRED m <br /> Lar Lr ki <br />