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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratoro 0 <br /> -APPLICATION FOR - LAND USE - PERMITS 3 = <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <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 C <br /> regulations of the State of Wisconsin. <br /> A" - ik <br /> NV �-�n Nseo SG lM,e� n f <br /> OWN�ET,(,11e ePgo%nt), Contractor or Surveyor or Agent <br /> / I✓t✓ Rt <br /> m <br /> Ad¢tess Address <br /> �J `CtN (nN`/ � (� <br /> City, State,Zip qode City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name $961 B I-ac✓` V. <br /> Legal Description (as Indicated on tax statement) o <br /> n � <br /> Permit(s)Applied for: <br /> 0 <br /> Dwelling Addition e Filling/Grading Camping Unit S <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage .� <br /> r � 1 <br /> Structure Use: — A��t �'e N II,AC� 4fNf1 - I V1, 1 a K-� 5 <br /> (family home/cabin, garage, addition, etc.) <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 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (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. z v <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building P w <br /> to lake, river or stream, if applicable. M <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 <br /> I: <br /> PLOT PLAN y (\ <br /> a—l. <br /> fn <br /> 0 <br /> 0 1 <br /> v � <br /> n <br /> y Ill <br /> — <br /> z <br /> a <br /> r" <br /> f <br /> mo c mN m o n F r�Tl <br /> v aa� maH a � � <br /> Z o ? m , 0. <br /> :°2 rD 3 <br /> P m <br /> g ` a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.1 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- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I f <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- 1' --J/ <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 1 <br /> N <br /> access to the above described premises at any reasonable time for the purpose of inspection. - --- m 8 M <br /> T 3 m <br /> m a n e: <br /> m : m <br /> SIGN HERE <br /> (sign ur of owner or building contractor) <br /> 17 L <br /> ZONING ADMINISTRATOR Cy--�Rr�1 (\�(]� <br /> 11VU I I�7.7V 1, NNONT <br /> TOWNSHIP PERMITS MAY BE REOUIR u v u v o o m <br /> 8888888ro <br />