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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -. 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <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 3 n <br /> regul�atpn of the S�ite of Wisconsin. <br /> SUPS �l00—r-D r y <br /> n E <br /> 011z , (P,lee Rrint) Contractor or Surveyor or Agent o <br /> II [i� a <br /> Addre s 54 q0 Address <br /> -1 ,Pr W� <br /> City,Stat ip Pode C l moi/ City,State,Zip Code Q <br /> Tee hone Telephone (� <br /> 5MG I oIct 35 kbA <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: o <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit 6 ° <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° $ <br /> Garage <br /> Structure Use: I 1 r <br /> family home abin, garage, addition, etc.) o <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 dreinfleld (DF). 0 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 P c <br /> 300 ft. o n <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. m Ifr 11 <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. (A }Z� <br /> PLOT PLAN lI I� <br /> h <br /> Z <br /> O m <br /> /P1 V <br /> 0 <br /> N <br /> 0 <br /> o <br /> a <br /> Z <br /> m o c m m 0 a F m <br /> v m <� .2 Cp oma <br /> P o` : m .Z : '1 <br /> CZ M <br /> Pte : Trn [ [ a <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- D <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 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 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 /> m A q t <br /> m m <br /> H 'a <br /> SIGN HERE ` J'I a <br /> (signature f owner or uildi contractor) (date) <br /> ZONING ADMINISTRATOR <br /> Q MN +NHNNT <br /> TOWNSHIP PERMITS MAV BE REQUIRED u v nn o o m <br /> 888888$ 8N <br />