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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator ? M 0 o <br /> APPLICATION FOR — LAND USE — PERMITS - 3. _TO THE 21NING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � m -� <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m 0 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. O <br /> m °1 <br /> n � O <br /> lease Print) Contractor or Surveyor or Agent <br /> OWN R(P77 o <br /> f /ill <br /> Addry�s Address <br /> < /'fCo�/.tll __5� A � <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone ) <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit o <br /> Privy Subdivision m -<-' <br /> °r. <br /> Structure Use: <br /> family home abin,garage, addition,etc.) 0 0 <br /> 0 <br /> m <br /> Directions for plot plan drawing: _ <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)and indicate North(N). <br /> 2. 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, <br /> river or stream,if applicable. Ji <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6. Provide legal land description. O <br /> 0 <br /> PLOT PLAN <br /> a N <br /> c <br /> Z <br /> o a a <br /> U F <br /> > 0 <br /> IL <br /> J <br /> t <br /> 0 <br /> _ <br /> N <br /> s <br /> 73 <br /> 0 <br /> A <br /> T <br /> tD <br /> Z <br /> 0 <br /> ( � D <br /> I 1 <br /> c_ wr0 acmm <br /> 0 cr o n-.m <br /> LD. L. 0 ^;n <br /> Z w Z3 . <br /> o [ 1 <br /> O: <br /> �; m <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my S <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> A <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a ? o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> Qm <br /> SIGN HERE <br /> (sign re f owner ilding contractor) date) <br /> o <br /> ZONING ADMINISTRATOR �� o: <br /> o: o <br /> T <br /> N <br /> N O N 8 +o N m <br /> 0 0 <br /> TOWNSHIP PERMITS MAY BE REQUIRED P,P P m <br /> 000000 <br /> 0000000Ul <br />