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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co d '00 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. — <br /> iu <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v 9 <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 <br /> regulations of the State of Wisconsin. H 0 r� � <br /> N N O <br /> PO ILIA � iTe )�L�J!'.� a $ <br /> OV ER (Please IPrint) Contractor or Surveyor or Agent o <br /> � � � <br /> Ad ress Address <br /> /NC lScaNv 0A/ 55 'ate Y <br /> CitState, Zip Code City, State,Zip Code <br /> 307 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> O 0 <br /> v J <br /> z <br /> Acce dina Sanitary Privy Subdivision ° m <br /> arage ^^ rr <br /> Structure Use: _f h o.'`7 h( <br /> (family home/cabin, garage, addition, etc.) 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O (At <br /> 2. Show the location of the well (W),septic tank (ST),and drainf laid (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 i91111 <br /> np mill <br /> 300 ft. o <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m � �F. <br /> to lake, river or stream, if applicable. C <br /> ? 'll <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. 40 <br /> I (` <br /> PLOT PLAN — <br /> S kJ <br /> L' j CA <br /> � o <br /> N <br /> O <br /> � l <br /> 40 ' <br /> w <br /> ZJ <br /> !� Z <br /> T <br /> m o c m n F <br /> m m !.5. Co ami <br /> a <br /> z m o A Z M <br /> P F T y? p <br /> n _ m <br /> C <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m m 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 1 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 ,/� $ 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 have Ou, o <br /> access to the above described pr 'ses at any reasonable time for the purpose of inspection. m $ m <br /> A A <br /> L I N <br /> VI <br /> SIGN HER <br /> (signal r f owner or ng gontrector (d el <br /> it<Z <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PE ITS MAY BE REQUIRED IJV N N N o o S m <br /> / 88888888fmn <br />