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(,Y � <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 00 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. ' <br /> o , <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w i� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the a <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. a <br /> jots` 3ovJMk Stl� a o <br /> OWjR Fee Print) Contractor or Surveyor or Agent o `m <br /> ,Ad� WEE =LL- (OM31 Address <br /> lCit State, ip ode City,State,Zip Code " <br /> 108 -�23— 89 G•7 L <br /> Telephone Telephone i <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) J <br /> n 0 <br /> 0 <br /> Permit(s)Applied for: 0 »- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit ° j <br /> Z o J <br /> Accessory Building Sanitary X--. Privy Subdivision ° _ - <br /> Garage <br /> Structure Use: o <br /> (family home/cabin, garage, addition,etc.) <br /> 0 <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 /> O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 0 v, <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- If within an <br /> Z <br /> 300 ft. o o 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 o <br /> to lake, 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 C <br /> dated by the owner. mJ a <br /> PLOT PLAN r� <br /> , <br /> � <br /> a"r 7 <br /> m <br /> w <br /> f' I <br /> m o c m m n F m <br /> mm a1D M <br /> o <br /> 0 :5. : Z H o 0. 3" <br /> t c)� ' ID <br /> c <br /> 8 : a _ : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o I ' a `� [ 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- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i ? 25 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a permit. I g 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ <br /> V A m <br /> SIGN HERE <br /> of <br /> (signal re of owner or build'n contra tor) (date)_. _ o a s <br /> ZONING ADMINISTRATOR ULT 1 <br /> 991 ' I <br /> m <br /> www�x <br /> TOWNSHIP PERMITS MAY BE EOUIR0 `� & 8 o 8 m <br /> f <br /> IU 888rmn <br /> i <br />