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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w T o O <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the '^ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin..... y m <br /> Tat J., jl; <br /> OWNER (Please rint) I Contractor or Surveyor or Agent o <br /> — <br /> Address Address t <br /> City, State, Zip Code City, State,Zip Code <br /> �.IZ - o <br /> TT�phoneab lJ--fKe VoprD Telephone <br /> Emergency/Fire No. and Road Name K <br /> Legal Description (as Indicated on tax statement) <br /> o 0 <br /> Permit(s) Applied for: o �- <br /> J ^- <br /> u, � <br /> Dwelling Addition Filling/Grading Camping Unit °- <br /> v <br /> z o <br /> Accessory Building — Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: Ca {ti <br /> /" (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M 0 <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 -0 <br /> 300 ft. z Q <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road, (c)building o y <br /> to lake, river or stream, if applicable. fit o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. y_ m <br /> „ r <br /> PLOT PLAN <br /> Lev �- <br /> N <br /> eco <br /> �e o <br /> P�e,a1� R71) <br /> y <br /> i Doc � mmoao � <br /> f m <br /> m. <br /> OO ry <br /> � J z =t : m <br /> -' m <br /> w o rm 3 rj ' C <br /> o : ao C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m , m <br /> 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infon $ d <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g <br /> further accept all liability which msy be a result of the County of Burnett relying on this information I am providing in this ap. N <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. g <br /> T <br /> SIGN HERE <br /> (si u of owner Ing contractor) (date) <br /> o . x : <br /> ZONING ADMINISTRATOR g <br /> TOWNSHIP P RMITS MAY BE REQUIRED <br /> ut N N N O O O m <br /> ggggggggN <br />