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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator � � a o <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0 <br /> tions of the State of Wisconsin. y m -L <br /> n <br /> OWNED(lease Print) Contractor or Surveyor or Agent <br /> / S / HL' <br /> A dress __ Address <br /> VQA /urs <br /> City,State,Zip Cod6 City,State,Zip Code �e <br /> J <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> o <br /> Addition Moving � O <br /> Sanitary �_ Camping Unit o ° <br /> Privy Subdivision 'm <br /> I� ° o <br /> N v tAhl l 1 A ��((V l - <br /> Structure Use: Z <br /> (family omelhalhi n,garage,additiion,etc.) P <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings it JB)and indicate North (N). C,1 <br /> 2. Show the location of the well(W),septic tank(ST),and draihffel'd IVIF)i. <br /> 3. Show the location of any lake or flowage-if within 1000 ft.and1he location of a ny river or stream -if within 300 ft. ) <br /> 4. Show dimensions in feet of the following:(a)building to all lotlines,(b),building t o center line of road,(c)building to lake, <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,.contractor,etc..,the plans must be signed and dated by J <br /> the owner. 6 Provide legal land description. <br /> 3 <br /> PLOT PLAN z c <br /> O a= <br /> 2 <br /> w� <br /> o� <br /> i <br /> J <br /> u. <br /> aQ- <br /> o <br /> 0 <br /> F <br /> � I <br /> Z <br /> �j/� L o <br /> / J z <br /> m c� %r- ncmm <br /> m n� m aa E. <br /> -' <br /> o M m 3 <br /> y : O <br /> M <br /> o: <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all <br /> m <br /> - A <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> o : <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o , <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing n <br /> 1n this application. <br /> person toha eaccess tothe permit <br /> county describedfficials charged with p premises at any reasonable time gforthetpurpoordinances <br /> se of inspection.tauthorized <br /> T <br /> N <br /> 5 � <br /> SIGN HERE (date) <br /> ( natu a of owner orb contractor) <br /> o: <br /> o: o <br /> E E o f E i o <br /> ZONING ADMINISTRATOR <br /> N N O N N m <br /> To <br /> PERMIT AY BE REOUIRED v n v U o o v <br /> og00000fmq <br />