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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. 0 <br /> d <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 m - <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. y m a� <br /> REV ?5 9 S t a m f <br /> OWNER PI se Print) Contractor or Surveyor or Agent o <br /> "Lsj z1) UrL MAI I K . RD- <br /> A 1jS .�. Jl \�. -5 sc _ Address <br /> City, State, Zip Code W �� City, State,Zip Code /In <br /> Telephone Telephone t <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> O <br /> Permit(s)Applied for: 0 4 <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit 0 o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision p <br /> Garage <br /> Structure Use: i-FaR r <br /> 0 <br /> (fkmily home/ bin, 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). n <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfield (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 o <br /> 300 ft. o b a I <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m G y <br /> to lake, river or stream, if applicable. T E <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 Z nl <br /> PLOT PLAN � Tit I� <br /> 1 'n <br /> o IN <br /> m <br /> a <br /> a <br /> ( Z <br /> "11 <br /> 1 <br /> m o c <� m m o a F ren <br /> A. D6� s6 H dq 31 <br /> Z <.S '25000. 03 <br /> P ;,N a <br /> m <br /> u m c C <br /> 8 ; i A a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe detail and accuracy of all informs- w m 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. 1 E $ m $ <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 u <br /> access to the above described premises at any reasonable time for the purpose of inspection. w g <br /> n <br /> N H <br /> SIGN HEREa <br /> (si a re of ow uilding contractor) (date) o x <br /> ZONING ADMINISTRATOR <br /> www wwwT <br /> TOWNSHIP PERMITS MAY BE REQUIRED N 00'00 b m <br /> 8888888ro <br />