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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Z -10 a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> q <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with uyy�mer�w�t m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable i{iry{iOrdina�r4d4ha 3 a <br /> regulations of the State of Wisconsin. m <br /> �( n f <br /> OW ER le se not - Contractoror Surveyor or Agent o _ <br /> Addre� Address <br /> City, St e Zi __ City,State,Zip Code 'A <br /> Telephone _� �✓ Telephone <br /> EmergencY/Fire/1 <br /> 19121111 M _; and oad ame / 1 <br /> Legal Description (as indicated on tax statement) <br /> 0 <br /> Permit(s) Applied for: 0 'C. <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> 0 o <br /> Accessory Building Sanitary Privy Subdivision ° ,00 <br /> Garage <br /> 0 <br /> Structure Use: % x ! //�{�[1/�� ( J/��� r <br /> (family me/cabin, gafage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (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 <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 m m I \ <br /> to lake, river or stream, if applicable. cJ <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and (; 1 <br /> dated by the owner. m <br /> PLOT PLAN o¢ <br /> I <br /> m <br /> m <br /> 0 <br /> o <br /> J) o <br /> m <br /> o <br /> m o c m m o a <br /> m <br /> mm °- =. 3 <br /> N <br /> 9 F [ T42 ' M <br /> m <br /> u : GCcE O <br /> m � C <br /> g : mm <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- M <br /> o 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 row ; V <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro u <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 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 O o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 80 <br /> m U N <br /> m m A <br /> SIGN HERE - &(signs re of owner or building contractor) 1 (date) o , <br /> ZONING ADMINISTRATOR g ' ((/�� <br /> TOWNSHIP PERMITS MAY BE REQ RED N N O O O m <br /> 88888888 vi <br />