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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Admin sa <br /> try for " d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 £ <br /> d _ ¢ <br /> z g r$_ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located ae shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur <br /> - <br /> ne.tt 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. m <br /> N � <br /> OWNER(Pleas,e/IJJPrint) Contractor or Surveyor or Agent £ <br /> m <br /> Address Address <br /> au,,.„<.�,�/F_, ��,z✓ .5533 � <br /> City State,Zip Code City, State,Zip Code (n <br /> �/S , �j� -iyyY <br /> Telephone Telephone "P <br /> 1 <br /> Emergency/Fire No.and Road Name d <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: ( o I <br /> New Building Sanitary Filling/Grading Camping Unit y <br /> r <br /> Addition Privy Moving Subdivision o ° <br /> v <br /> Structure Use: o <br /> (family home/cabin, garage, type of addition, etc.) <br /> Directions for plot plan drawing: <br /> V <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). O <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. <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 ordi- <br /> nary high water mark of lake, river or stream, if applicable. 1 <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by o <br /> the owner. <br /> 3 <br /> PLOT PLAN rd <br /> Z c <br /> 0 0 <br /> n <br /> 5 <br /> N <br /> � O <br /> Sbq ' c <br /> rn76 <br /> L c <br /> C> <br /> U! <br /> Q � <br /> Bc�G <br /> 0 <br /> Hm <br /> ��PIOC o <br /> f iL C,,v <br /> J o <br /> 514 out -fl-6m <br /> I <br /> I� <br /> liw�r m M <br /> Orr���� w� v et� �s T� �/ d � o[ o <br /> � 'r / i] <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- A i m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I O” a <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 <br /> -- access to the above described premises at any reasonable time for the purpose of inspection. <br /> - ' <br /> (Ai <br /> SIGN HERE <br /> (sig ture owner or bu contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> r. $oo o$g Ul <br /> f <br />