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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the �^ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> ��E Tress <br /> ease PSi ttI` y Contractor or Surveyor or Agent o <br /> ress jAddress <br /> ST. dirt n �r� 7_r !� <br /> City, Stat Zip Code City,State,Zip Code <br /> 7i.)- - ys-57- <br /> 1 eleprione 3 o 3 Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) q <br /> o (` <br /> Permit(s) Applied for: o` < <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: L! <br /> 0 <br /> (family home/cabin, garage, 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). M n <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (DF). 0 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 3 N <br /> 300 ft. z Q <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c) building n o s <br /> to lake, river or stream, if applicable. m1 i' o <br /> 5 .If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C t I ' <br /> dated by the owner. n 0 (� S <br /> PLOT PLAN �j - 3 L(2 <br /> I <br /> -Ij N <br /> O <br /> 7 <br /> O I� <br /> o I <br /> YV <br /> O <br /> l � l <br /> k' A - a'� K 'a2 aL 71 <br /> C <br /> Q 7 T� <br /> N m <br /> i3n C <br /> 8 ci <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m `� 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- N <br /> mation I am providing will be relie on by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m g <br /> further accept all liability which be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. I agree to permit cc y fficials charged wit"ministagng county ordinances or other authorized person to have N <br /> access to the above desc ' emises at any reaso aqfe tim_30dr the purpose of inspection. m 3 g <br /> N A A N <br /> SIGN HERE w <br /> g ature of ow building cont tor) (date) <br /> o : x : <br /> ZONING AD NISTRATOR -0-7 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> P1 0 . 88 m <br /> 8889 988vmi <br />