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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0o 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 H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <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, <br /> OWNER (Please�PIint) Contractor or Surveyor or Agent o <br /> 3 6 .7 l- l r <f 77 <br /> Address '99 Address <br /> (rV , <br /> S i � u l S c . .'� <br /> City, State, Zip C e City, State, Zip Code Ul <br /> Telephone Telephone �✓� <br /> Emergency/Fire No. and Road Name �J <br /> Legal Description (as Indicated on tax statement) o <br /> —1 <br /> n O <br /> Permit(s) Applied for: a °- <br /> N r- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v �J <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: D(?,-'\r/ <br /> (family home/cabin, garage, addition, etc.) <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). A 0 <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 11 P <br /> 300 ft. z 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 n P s <br /> M <br /> to lake, river or stream, if applicable. M <br /> y <br /> 5. If,separate plans are submitted by an architect,engineer,builder,c tractor,etc.,the plans must be signed and C <br /> dated by the owner. -- 0 <br /> P OT PLAN <br /> � v la �C /cam I i <br /> Zx pp o <br /> -- h <br /> N IY�/ <br /> OQec w <br /> h-IL7 Orr <br /> N <br /> z <br /> PECK- AD' T - <br /> ,A C <br /> c <br /> J m _ <br /> o m om ,2 1 <br /> F T y <br /> M <br /> n N s to <br /> v I g P n E i C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- r' o m M <br /> 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 8 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g 0 <br /> 3 ^ N <br /> 2 / 6 N ry A <br /> SIGN HERE (/AVL,`.',''iL' o' rn g <br /> (signature of owner or buildin contractor) (date) : v <br /> ZONING ADMINISTRATOR •� 8 : <br /> TOWNSHIP PERMITS MAY BE REQUIRED N No N m <br /> N N V O <br /> 888888 8m <br />