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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - o 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 y <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <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 Wisconsl ,, ff m w <br /> TDa 10 <br /> kv /Uri r f rn C ` f <br /> OWNER Please Print) Contrac or o Su eyor rAge v <br /> a��`(Dram � �c��) <br /> Addre Address <br /> 0 <br /> tlr(1L <br /> City, State, Zip Code City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n 0 <br /> Permit(s)Applied for: 0 0- <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o ° <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage <br /> Structure Use: <br /> 0 <br /> (family 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). <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 P c <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 mH <br /> to lake, river or stream, if applicable. 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 <br /> dated by the owner. m L <br /> PLOT PLAN Ij <br /> --9 <br /> u^ N <br /> vo <br /> N C Imo- <br /> O <br /> J <br /> m <br /> N <br /> G- Z <br /> 9 <br /> mO c M. m m o a F <br /> m2 y <br /> Z5 o 0. m3 <br /> n m <br /> � �2 0 <br /> 8 n ` 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 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- '" : w m w <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 'msµ, i? 3 N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 U 8 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described remises at an reasonable time for the purpose of inspection. 1[ : m 8 m . <br /> P Y O : [-[ E 3 A H i <br /> ry N pA <br /> H N 8 <br /> SIGN HERE j' a <br /> (signature of owner or building contractor) (date) o �, <br /> ZONING ADMINISTRATOR I(Yl 1'�la'fIIC^oar) 8 ' <br /> wqr� �(j, <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N 0 0 0 8 m <br /> 8 $ $ 888 $ $ x, <br />