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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o 0 <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 � m <br /> located es shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regula ions of the State of W' sin. y .i <br /> mon tw. y r <br /> �t.A $ S <br /> OWNaPript) F-J f Contractor or Surveyor or Agent 'o <br /> Address ll 1 [v dress <br /> City, StAle <br /> i ip 24 -Coe 07 o % City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> Permit(s) Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit R <br /> v <br /> Z o <br /> Accessory Building Sanita Subdivision ° M <br /> Garage <br /> Structure Use: C1 't <br /> (family home/ abin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 4M , <br /> I <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 ? „� <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). C 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 11 c <br /> Q :l <br /> 300 ft. 11 Zo 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 y: <br /> to lake, river or stream, if applicable. m <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H <br /> dated by the owner. <br /> M <br /> PLOT PLAN <br /> q� Ci <br /> d <br /> 0i <br /> y <br /> b <br /> I <br /> m <br /> °- S M <br /> 4 m N 3 <br /> X3b � � � o ,f ° <br /> 9 <br /> p� [ ' O <br /> v, <br /> I declare that this application(in lu'di g any accompa*g chedu e)has been examined by me and to the best of my knowl- 9 m m <br /> edge and belief it is true,correc and mplete.I acknowledge that I am responsible for the detail and accuracy of all informa- w m(» : O <br /> tion contained in this applicati n(incl ding any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied pon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 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- d, <br /> lication.I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> ,as to the above described premises at any reasonable time for the purpose of inspection. m g <br /> -n 3 n <br /> F : <br /> pA u <br /> M <br /> C <br /> (si tur of owner wilding contractor) =-- '(deEe) '. <br /> RATOR %L4G 18 ' <br /> I <br /> TOWNSHIP PERMITS MAY BE REQUIRED ii I � N N N N f f ut <br />