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Burnett County 7410 Co. Rd. K, ¥102, Siren, WI 54872 Office of Zoning Administrator 0Z <br /> 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> ;v o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Z <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. m <br /> nett 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 m OO <br /> N v <br /> Jl� tC A A: / -P H'r /' 11 S /Fe a O <br /> OWNER(Please Print) Contractor or Surveyor or Agent o r <br /> Addre s Address 6 <br /> tVtr. �Tr u11 . S lYY3 <br /> City,State,Zip Code City,State,Zip Code C� <br /> i <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n o I <br /> Privy � Subdivision m <br /> Structure Use: � <br /> (family ho a/cabin, garage, addition,etc.) o 0 <br /> a <br /> m <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). <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, Y 1•. <br /> river or stream, if applicable. <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. <br /> 1 <br /> PLOT PLAN .o w <br /> XPIRIE'b <br /> o <br /> S + TPA-It <br /> , <br /> e <br /> r' <br /> e � <br /> r � � 0 <br /> N <br /> O <br /> 1 <br /> T r <br /> N <br /> /j C ft o c Z <br /> J <br /> N, <br /> c�N n nc°� <br /> 0 a< n n- m <br /> LD. a� - m n M <br /> v y. p n Q 3 <br /> Z o <br /> �': m <br /> n D <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 <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 /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that ^ I O <br /> PP (� 9 Y ) 9 n <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 u, <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 /> m <br /> m <br /> SIGN HERE— <br /> (sigportiine of ownepVr building contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> n-I <br /> TOWNSHIP PERMITS MAY BE REQUIRED N m <br /> 0000000 <br /> o000000fA <br />