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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator 0 M0 a <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. �. <br /> � m m <br /> VCfrll',( d �iJL� `�r11r�SUY1 TUB; �.P. 'nL� a — 0 <br /> OWa(Please Print) Contr or or SurveYy,�oror Agent <br /> Add '5141-1 ss Addr _ <br /> 1( 1 l �,q�' )A CL41 kL -- '5141-1to <br /> City,State,Zip Cod City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving 0 <br /> Sanitary Camping Unit n 0 CO <br /> o <br /> Privy Subdivision <br /> r <br /> S o 1 <br /> Structure Use: l�1 <br /> (family home/cabin, garage,addition,etc.) o v ? <br /> m <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). <br /> 2. Show the location of the well(W),septic tank(ST),and drainfield(DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 300 ft. D <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted b an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6. Provide legal land description. <br /> 0 <br /> 0 <br /> PLOT PLAN 3 <br /> Z a <br /> o n <br /> N <br /> O <br /> i <br /> s N <br /> n <br /> a <br /> 0 <br /> _o <br /> y <br /> n r <br /> Z <br /> N <br /> J Z <br /> O <br /> I Z <br /> D <br /> m c �.mmnnr= m <br /> n o•< o ooa— <br /> a N m p '0 3 <br /> w[ ; m <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oo [ <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> (si ature f owner orb contractor) (date) o€ ; o <br /> ZONING ADMINISTRATOR `��� I o? o <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O N N m <br /> �cn u,v,v,o o cn m <br /> 00000$oV <br />