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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Q) m o a <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of theI CD <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> egulations of the State of 1Yisco sin. w Rt <br /> l \ <br /> zu �� rtE j� �cr i�? � �i:C� rd a Jf <br /> OWNER (Please Print)c Contractof or Surveyor or Agent o <br /> �V�D 1! �'-r L C Vd ,. <br /> m _ <br /> Ad r� I Address T' <br /> City, State, Zip Code City, State,Zip Code <br /> Telephone Telephone ) k- <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> c> <br /> Permit(s) Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit °- <br /> z <br /> v - <br /> Accessory Building Sanitary Privy Subdivision P ' <br /> Garage—Cl } <br /> Structure Use: . 6, 5k o - <br /> r <br /> 0 <br /> ` (family home/cabin, garage, addition, etc.) mill <br /> DIRECTIONS FOR PLOT PLAN DRAWING: Q <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). 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 rn <br /> 300 ft. z `v <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building n .. <br /> to lake, 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 C I <br /> dated by the owner. a <br /> m <br /> PLOT PLAN / <br /> rn <br /> /JD e s V <br /> /W N <br /> o � <br /> e- d <br /> C <br /> hU � 5 F 0. .0 �i age <br /> - P� a <br /> m nam Imo <br /> — ° — 3 <br /> _.. 9 < � `Zw 0' SO <br /> f J My n <br /> G) 2 m <br /> � [ O <br /> S <br /> m m € a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all Informa- = [ yr m y, p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this info- b"ro cam„ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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- I N <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 real nable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> gn ure ofowner r ui Ing contractor) (date) .r <br /> ZONING ADMINISTRATO <br /> T <br /> TOWNSHIP PE MITS MAY BE REQUIRED N N N N O O O m <br /> 8888888rmn <br />