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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the tate of Wisconsin. = o <br /> c l �etirrb r 4P)rUaf1: <br /> OW R.(Pleas Pri ) Contractor or Surveyor or Agent a v F <br /> .�. a O f1 m <br /> m <br /> Address ` Address m <br /> ltirc b 5�r <br /> City,State,Zip Code City,State,Zip Code I <br /> i <br /> Telephon Telephone <br /> L d.un..ta><.sialecgP,O,t,�. O <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit `- <br /> m r <br /> Addition Privy Moving Subdivision g a <br /> v <br /> Structure Use: - <br /> (family home/cab(n, garage, add tion,etc.) <br /> . Show the locat;iion and size o all existing buildings(EB)and all new buildings(NB)and indicate North (N). <br /> . Show the location of the well(W) septic tank(ST), and drainfield(DF). <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 lake, C <br /> river or stream, if applicable. M n , <br /> 15. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated byO o <br /> the owner. <br /> 71a m <br /> PLOT PLAN '11 Z `Q <br /> M — y. <br /> C L i 0 c <br /> I <br /> N <br /> z <br /> 0 <br /> a I� <br /> D I 1 <br /> m <br /> � I <br /> X Z <br /> � D <br /> m c�miu �acm� <br /> m al '=am Ras <br /> m <br /> Vto i Vic`. ' i O <br /> g i m c i i C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowk S <br /> 56 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- : : 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 <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. m w»A <br /> m3 o : <br /> ( ign'a�ture�o^f owner or building contractor) (date) o? g <br /> ZONING ADMINISTRATOR SII[' f. r�wlgDn <br /> rn <br /> v wur fnrn <br /> TOWNSHIP PERMITS MAY BE REQUIRED S SA $$$M <br /> f <br />