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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <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 '2 is <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. y <br /> XW 7-6/2 16 NN Se) A) a o <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 6X/S /27/A4s,C09V l9tIE. S�,_ <br /> Address Address <br /> 2ieN fiE< a IVAJ Ss,4/a 3 <br /> City, State, Zip Code City,State,Zip Code <br /> (6/4 869- <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> � a7— 5' s�roN 7 'va ' iy Seo �u�vsc<iP <br /> Legal15eacription (as indicated on tax statement) o <br /> Permit(s)Applied for: o o <br /> J <br /> �^ r <br /> Dwelling Addition Filling/Grading Camping Unit o °— <br /> v <br /> Accessory Building X _ Sanitary Privy Subdivision ° <br /> Garage <br /> i <br /> Structure Use: <br /> r <br /> (family home/cabin, garage, addition, etc.) Mill <br /> 4 ° <br /> DIRECTIONS FOR PLOT PLAN DRAWING: O <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). (�- <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (DF). <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. 71 Z W cv <br /> o n <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 /> to lake, river or stream, if applicable. III Z o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C J <br /> dated by the owner. <br /> PLOT PLAN <br /> � C <br /> I a <br /> tJ4� <br /> 0 <br /> J <br /> m <br /> C�F/i3i.ci S�Pr' = �r <br /> \\ /2R ti Z . <br /> l _ <br /> m <br /> Oo 2 <br /> N <br /> 8 : 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 informa- m <br /> 9 P 9 P Y <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 8 m 8 <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 haveut <br /> access to the above described premises at any reasonable time for the purpose of inspection. ro ' <br /> m 3 8 n <br /> a m <br /> SIGN HERE f�iL <br /> T n <br /> ( ' na re of o Xer r uilding contractor) (date) <br /> ZONING ADMINISTRATO 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N " <br /> ut Oi toU 880(� m <br /> 88888 $ $ 8 a, <br />