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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -- 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 as 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 n <br /> 0 <br /> regulations of the State of Wisconsin. <br /> a f <br /> (Please Pri t Contractor or Surveyor or Agent <br /> �^Iry$U R� ' • ` 6 , ���p .� Address ( � <br /> City, State, Zip Code W` `u City, State, Zip Code v t <br /> Telephone Telephone <br /> i <br /> Emergency/Fire No. and Road Name G <br /> Legal Description (as indicated on tax statement) f1� <br /> n G1 l/1 <br /> 0 <br /> Permit(s)Applied for: <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> ' <br /> Structure Use: ' " "I <br /> (family home/cabin, garage, addition, etc.) ( <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M p <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). 3 u, <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 <br /> Mill! Z `v <br /> 300 tt. ° <br /> M <br /> 4. Show dimensions infeet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building � <br /> to lake, river or stream, if applicable. <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andC O <br /> dated by the owner. <br /> PLOT PLAN ( '. I.... <br /> C) <br /> A CtEE� ( <br /> Jm <br /> ° <br /> J <br /> m <br /> w Ar <br /> $ ` z <br /> 1 )3Er/74— <br /> O c b m chi 6 Mo <br /> PZ f 0 i �� M <br /> = = : i m <br /> 3 = c <br /> 8 m M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m w [ O <br /> tion contained in this application(including any accompanying schedule)and 1 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 $ m $ <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 o <br /> access to the above described premises at any reasonable time for the purpose of inspection. ' m $ m <br /> n 3 n <br /> m g A m <br /> A AA <br /> SIGN HERE <br /> (signature of owngircpbuild g c tr (date) o x <br /> ZONING ADMINISTRATOR <br /> (Vq w w(w� � <br /> TOWN HIP PERMITS MAY BE REQUIRED N N N O O O m <br /> 88 8888rmn <br />