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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z s <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 Bur- m m ill <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�Wiisconsin. f m o <br /> RQ 1e /1 CI,G /Y A) SL' m m <br /> C <br /> O <br /> OWNER lease Print) / Contractor or Surveyor or Agent <br /> � 0 31 o�� �ia�cr Au N <br /> Ad resse n Address n ' r <br /> City,State,Zip Coe City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) Ci v <br /> Permits)Applied for: c� <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit »- <br /> v, r <br /> Addition Privy Moving Subdivision o 0 <br /> Structure Use: o o <br /> (family home/cabin, garage, type of addition,etc.) _``,, <br /> Vv <br /> Directions for plot plan drawing: J <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). Y y <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 ordi- <br /> nary high water mark of lake, 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. o f <br /> PLOT PLAN <br /> Z c b <br /> n <br /> N <br /> O <br /> °f I <br /> �1 V ' <br /> 10 <br /> t <br /> _ n <br /> 0 <br /> O <br /> O <br /> 0 <br /> It, <br /> Z <br /> IL <br /> a�000aC <br /> 0Q< 000a= <br /> o 3 <br /> n Z 0 0 a <br /> M <br /> —ter: m <br /> v : [i <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. of <br /> o : 0 : y <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa- m <br /> tion contained in this application(including any accompanying schedule)and I 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 t}(�• a <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> (si a re of ownypf building contractor) (date) `: o <br /> ZONING ADMINISTRATOR <br /> v -I <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 m <br /> 0 0 oogN <br />