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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m c c <br /> _ � f <br /> APPLICATION FOR — LAND USE — PERMITS <br /> 0 <br /> TO THE ZONI MINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c <br /> located asshown 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 __ a <br /> regulations of the State of Wisconsin. <br /> It <br /> W <br /> Jv��/I4� •T ��— n f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> at <br /> Addre Address <br /> City, State,Zip Cod '7 4erryv City, State,Zip Code <br /> n�� PSO 7 4 <br /> Telephone r Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n � <br /> Permit(s)Applied for: <br /> Nr. <br /> Dwelling Addition Filling/Grading Camping Unit S <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage :&Structure Use: I "k / hock/ P C) o <br /> (family home cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). n <br /> 2. Show the location of the well ('W),septic tank(ST),and drainfield (DF). 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 P c <br /> 300 ft. f. o or <br /> 4. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building A <br /> to lake, river or stream, If applicable. M 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. Jj <br /> M <br /> PLOT PLAN <br /> DOm <br /> P,0 7ha 0 10 <br /> n <br /> �a <br /> S <br /> oc_ °m� 0a m <br /> � m <br /> m = a g a in <br /> M 7D_. <br /> o m <br /> v ci = : s O <br /> ate : c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl• o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this Infor• 2S E <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 e g <br /> access to the above described premises at any reasonable time for the purpose of Inspection. roS <br /> T i i 3 A y <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) v <br /> ZONING ADMINISTRATOR <br /> H <br /> TOWNSHIP PERMITS MAY BE REQUIREDLn �N' o P . m <br /> 88888 8 W <br />