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Burnett County 7410 Go. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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 /> TM -m3OF11-014�5KI <br /> 0 N lea a nt Contractor or Surveyor or Agent o <br /> ) �U 'W w <br /> - d Address <br /> CiTy, State, Zip Code City,State,Zip Code <br /> I <br /> Telepho a Telephone <br /> q V V <br /> Emergency/Fire No. and Road I ame <br /> Legal Description (as indicated on tax statement) 71 <br /> n L) <br /> o _ <br /> Permit(s) Applied for: y »- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> ° <br /> Accessory Building Sanitary Privy Subdivision } <br /> Garage <br /> Structure Use: G <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). A O I <br /> 2. Show the location of the well ,septic tank S (DF). o <br /> (yV) p ( T),and drainfield � a N <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within Z <br /> 300 ft. <br /> 4. Show dimensions in feet ofthe following;(a) building to all lot lines,(b)building to center line of road,(c)building o <br /> to lake, river or stream, If applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and a <br /> dated by the owner. <br /> PLOT PLAN 1►� <br /> 1 � N <br /> `7 O <br /> 0 <br /> L <br /> z <br /> y <br /> r <br /> m <br /> a o < w 900 o o - <br /> 0 A o Z 1 <br /> � <br /> 2 O <br /> VJ 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- ' LJ o : 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 I further declare that I recognize that this infor- S' g o N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I p`'.1 $ m $ <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 n N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m 3 <br /> A4a_�9 _ <br /> SIGN HERE (/ <br /> (s' na re of owner ilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N T U N O O O n <br /> 88888888u <br />