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nq (w p' <br /> Burnett County 7410 Co. 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 5 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m Cc <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulatjgns of the State of Wisconsin. <br /> - <br /> M/ ' o m <br /> -a Id p-rdAAJ ) rfl�qrI< 1(raur a = o <br /> OW Please Pr' t) CoAractt(or mSSrveyor or Agent o <br /> jo <br /> Add IJ/1(V � EA9�7 AddrEss� s—T ,r . <br /> City, Stat, City, State, Zip Cod rVxjJ) <br /> Telephone Telephone t <br /> Emergency/Fire No. and Road Name ('�I <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o ° <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage .� <br /> Structure Use: r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) — <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 00 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfteld (DF). C 3 <br /> 11 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within <br /> 300 ft. o g <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 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. m <br /> PLOT PLAN hp� <br /> Ay <br /> L � —L3 to <br /> m <br /> O <br /> (`lo <br /> O <br /> J <br /> J <br /> O ti <br /> N <br /> Z <br /> 2! <br /> I <br /> I <br /> G <br /> 0 c c Z. o w a a : m <br /> < 4!F00 z3 <br /> Z m p 0 ,-.21 <br /> P f <br /> m <br /> o : ac C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o1D `� I 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- — d, n d, p <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. I g 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 a tii N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have vI <br /> access to the above described premises at any reasonable time for the purpose of inspection. . w go <br /> T 3 n <br /> A p ^AH <br /> N Ip Q <br /> SIGN HERE I '^ <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED N U N N N O O O m <br /> $ $ $ $ $ 88 $ rmn <br />