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51 M)Y-11 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w A o 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 m <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. �, o <br /> N <br /> C <br /> M <br /> 0 <br /> F <br /> OW (Please Pring �- � Contractor or Surveyor or Agent o <br /> Address/ / /� 4 17('IQ v_F Address t <br /> City, State, Zip Qoq City, State,Zip Code <br /> .., Ioc,A)is P I <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> C3 0 <br /> Permit(s) Applied for: o �- <br /> �' r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage -�- <br /> Structure Use: /o;-s+ '369 4 a <br /> (farKly home/cabin, garage, addition, etc.) <br /> 1A — <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 O <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 <br /> 300 ft. Z <br /> o a <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 s <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 /> a' <br /> PLOT PLASeeAw <br /> N <br /> JAI <br /> 0 <br /> 0 <br /> MAI <br /> n ! � <br /> s <br /> 6F\4I I <br /> o ®� �y�- 'A <br /> 'G._�,Z�6�" <br /> C v ? o D <br /> o ao V <br /> f m <br /> S A i o E o : r y D <br /> In <br /> � g <br /> I�CfarETiret this application(including any accompanying schedule)has eZi en examine y me a—n To'fFe bestoTTknbwl- o <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- Yi' 'm <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 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 <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. w g <br /> n <br /> SIGN HERE <br /> (si of owner ding contractor) (date) <br /> ZONING ADtA INISTRATOR <br /> www www <br /> TOWNSHIP PE ITS MAY BE REQUIRED 01 NNN N 8 8 m <br /> ( $ 8888 9 $ rmn <br />