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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Q) A a c <br /> 3 <br /> APPLICATION FOR - LAND USE - PERMITS ' <br /> m O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permtt r the work described and 'z y <br /> uI[ <br /> o \ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance .�requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County OrdinaMf36rantl the laws and 3 a <br /> re,�gu`ations of the State of Wiscoon�si / UT <br /> V Ae S'Cn a fV <br /> o <br /> �w <br /> OW E ase Prim) Coct <br /> Plentraor or Surveyor or Agent �/ m <br /> Add s r Address <br /> City, State, Zip Code City,State, Zip Code <br /> Telephone � Telephone );) <br /> Emergency/Fire No. and Road Name ) <br /> Legal Description (as Indicated on tax statement) ia <br /> o <br /> c> <br /> Permit(s) Applied for: o t' u_ <br /> Dwelling Additiony Filling/Grading Camping Unit ° 1 <br /> v <br /> = o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> i G <br /> Structure Use: _ o <br /> ff (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <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). 3 <br /> 3. Show dimensions in feet ofthefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building an Z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m , H <br /> dated by the owner. C 1 <br /> PLOT PLAN <br /> I t \ <br /> r P, <br /> N <br /> O <br /> 0 <br /> O � <br /> m <br /> Z <br /> I � <br /> O c� 0 0 a m <br /> va a'a a. - <br /> 0 <br /> 9 <br /> Z o o <br /> P f r a <br /> M <br /> o O <br /> g : <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- w N O <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 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 per cou officials charged with administering county ordinances or other authorized person to have 00 <br /> access to the above d premises at any reasonabl lim r e purpose of inspection. m 8 R <br /> I / tTD V A w <br /> SIGN HEREep <br /> (signat re of o nnje or building cc tractor) (date) 1Y o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDr <br /> i� , ooi� m <br /> gggggg $ grmn <br />