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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3.TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and o o <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 n <br /> regulations of the State of Wisconsin. <br /> }„ P rV\1 T� _ARSpV�6 n m f <br /> OWNER,(Please Pent) Contractor or Surveyor or Agent o <br /> II�� ((!!�) m V <br /> Adpress Address <br /> City, State, Zip CodeSy (/5� City, State,Zip Code <br /> b <br /> Telephone Telephone <br /> 3 02 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> 0 h <br /> Permit(s)Applied for: o` <- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Z 1 Accessory Buildingy Sanitary Privy Subdivision <br /> Garage / \ <br /> Structure Use: - _�h D <br /> amily home/cabin, 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). n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DIF). 0 3 <br /> Cn <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 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 0 'r y. <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. 0 <br /> PLOT PLAN 1 <br /> S � L v c�c2 � C G V-1 I <br /> J y <br /> O <br /> O r` <br /> O � <br /> w <br /> Z <br /> I <br /> m oc � mio oagm <br /> o oas <br /> 9a � aN a <br /> a m < m C m o S 3 <br /> m � � n M <br /> feso : TN M <br /> = m <br /> Vic : p <br /> 8 : aE C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S : 1° I m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- b" 'm N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 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- N <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. m 8 <br /> m 3 <br /> m : v > 'T : <br /> H m m <br /> SIGN HERE9� <br /> �/�-� N N 8 <br /> (signature owner or building contractor) (date) o , <br /> ZONING ADMINISTRATOR I,m TA711 An, <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N o o m <br /> 89888 $ $ 8N <br />