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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 1 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 � m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- mc <br /> nett County Land Use Ordinance nitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tion te,of Wiscons' <br /> C <br /> 07_,$,17a7Print Contractor or Surveyor or Agent n £ <br /> s <br /> Add m t <br /> J�� Address r? <br /> City,State,ZCity,State,Zip Code <br /> i Code <br /> Teleph ne^ r� G Telephone 1 (� <br /> /off.0 o U Q P, cS <br /> le <br /> Emergency/Fire No.and Road Name in <br /> Sc <br /> Legal Description(as indicated on tax statement) <br /> o <br /> m <br /> Permit(s)Applied for. o 0 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 ,`.- <br /> m <br /> Addition Privy Moving Subdivision o <br /> 0 C <br /> Structure Use: <br /> ^ V (family homelcabin,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). o <br /> 2. Show the location of the well(W),septic tank(ST),and drainfield(DF). <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within 300 ft. 1I <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, 0 <br /> 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 dated by 0 <br /> the owner. <br /> _ 71 3 y <br /> PLOT PLAN Z v <br /> o n <br /> 0 w <br /> I C p <br /> t <br /> 03 <br /> }A�O <br /> ��Ctzsda /r/Xo�o svrw,�os/ � c Iw <br /> � n <br /> s <br /> _-- <br /> v <br /> f <br /> m cyN�rDinc9 <br /> m $4 � nm nag <br /> a mi `Z10NO ; <br /> Z o: i , .2 i i -4 <br /> 5,9 6 0ci s <br /> I declare that this application(including an ac man In schedule has been examined b me and to the best of m knowl- Is g i '• IL- '• ' — <br /> PP ( 9 Y P Y 9 ) Y Y Off? mm : : 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- — - m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Q i ivr N O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I '• v,. <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 ab o scri d premises at any reasonable if for the purpose of inspection. O~ <br /> m m m <br /> SIGN HERE g <br /> (si atu a of owner=n contractor) (date) '• o i <br /> ZONING ADMINISTRATOR n $' <br /> Ni i f <br /> TOWNSHIP PERMITS MAY BE REQUIRED ""p"oo�dm <br /> 0188888880, <br />