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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d � 0 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 '? N <br /> lr <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 a <br /> regulations of the State of Wisconsin. d <br /> N � <br /> 122Q A&i .2 /i /Uu a f <br /> OWNER IeasePr' t)v <br /> Contractor or Surveyor or Agent o <br /> D. X� <br /> Addre Address <br /> City,State,Zip Code City,State,Zip Code 1 <br /> Telephone Telephone I �' <br /> Emer ency/Fire No. an a ame <br /> .ui.i %� fie. 6 7W.y iel0et <br /> L gal Description (as indicated on tax statement) o <br /> m <br /> n <br /> Permit(s) Applied for: o <- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: o <br /> (family home/cabi arage, additio tc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <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). e 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 <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 0 y. <br /> to lake, river or stream, if applicable. in C 0 <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. <br /> PLOT PLAN <br /> Ca <br /> o <br /> 01 <br /> Z <br /> N <br /> m o c -° m m o n g m <br /> awCza x <br /> N <br /> Z (p O N ,Z � <br /> P f i Mm € M <br /> = m <br /> 10 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S m `� m <br /> 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- <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- <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 premises at any reasonable time for the purpose of Inspection. ' a g m <br /> m V A N <br /> � N g <br /> SIGN HERE d' a <br /> (signs tur of owner or building contractor) date) <br /> o : <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REO" ED 8 8 8 9 m <br /> � 888rmn <br />