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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Co 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> N <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tionst e State of Wisconsin. m p <br /> ofduce Ter�Qu <br /> OWNER(PIS//��J)SS/g�,PRrint) +'7,/ / Contractor or Surveyor or Agent n E <br /> Address Address <br /> City, $tate,Zip Code /D City,State,Zip Code �S <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name 1 <br /> Legal Description(as indicated on tax statement) p <br /> m <br /> Permit(s)Applied for: � <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving / Subdivision 0 <br /> Structure Use: �Y/�/7Zl//l (�/7G(/ Z T <br /> 00 <br /> (family home/ca n, garage, typ of addition, etc.) g m <br /> 7L <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). �✓ <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. ( Il <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 ordi- <br /> nary high water mark of 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 dated by <br /> the owner. 0 <br /> 0 <br /> PLOT PLAN 3 <br /> m <br /> 2 c <br /> 0 a <br /> 0 <br /> I ' <br /> a' <br /> d <br /> a <br /> a <br /> J <br /> J o <br /> 0 <br /> V <br /> Z <br /> f <br /> a v m nnm � <br /> M c .m 0 as <br /> 0 0 0 a= m <br /> T. n m a M <br /> mo03 <br /> N <br /> 0 ,0 <br /> Z <br /> M <br /> o: C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- 'o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- y <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I (� a <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. <br /> T <br /> N <br /> SIGN HERE <br /> (signatur of owne or building contrac r) ( ate) o o <br /> of i o <br /> ZONING ADMINISTRATOR <br /> T <br /> N N O J N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED P v u oou m <br /> 0000000M <br />