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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o a <br /> APPLICATION FOR - LAND USE - PERMITS - <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v N U i` <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the N m v� <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. N R L <br /> m <br /> r aha_ \ -f a O <br /> f <br /> )WNER (Please Print) Contractor or Surveyor or Agent 'm <br /> 9Zo '3 or Z. <br /> Address Address <br /> 5 ir4 Inr t 5 P72, n <br /> City, State, Zip Code City,State,Zip Code <br /> z <br /> Telephone 1 3g S Telephone <br /> � - <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> o <br /> Permit(s) Applied for: 0 �- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° 0 <br /> Garage <br /> Structure Use: N1-IkEf� I 1 0 <br /> (fa ily home abin, garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O ' <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 <br /> 300 ft. o I <br /> 4. Show dimensions infeet of thefollowing:(a)buildingto all lot lines,(b)building to center line of road,(c)building m Iz <br /> to lake, river or stream, if applicable. 3 �L- <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. m r Ln <br /> PLOT PLAN <br /> I <br /> n z <br /> Art cNp <br /> 0 <br /> m w <br /> - w <br /> LA <br /> I� <br /> Z <br /> I IJ <br /> Ow c m m o n g m <br /> Dp � <br /> S <br /> c: 0 <br /> P m ,Z : <br /> P I Ty m <br /> _ [ m <br /> �i roc C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S - m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all in forma- 00 Fw O <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. 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 ap- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ; O u,o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 80, <br /> m 9 A m <br /> 10 <br /> SIGN HERE r (date) ' E <br /> (signature of owner or8 <br /> building contractor) O <br /> ZONING ADMINISTRATOR �)Arr t� r tL321'�7�i\� a . <br /> o <br /> TOWNSHIP PERMITS MAY BE REQUIRED o <br /> u <br /> 89 � $ $ 8ai <br />