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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o a <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 v m <br /> located as shown herein. The undersigned agrees that all work shall be a in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all oth a plicable County Ordinances and the laws and 3_ n <br /> regulations of the State of Wisconsin. ^/ <br /> g R � C) n £ <br /> 0 (Please Print) Con tact or Surveyor or m o <br /> 6 �fyv� Y - ei n�'y �9 _ <br /> e�4- to,,)kA Ad '- S 7cr � yr� n 1 <br /> Cit State, Zip Code City, State, Zip Code vJ <br /> = 38 <br /> Telephone Tel phone <br /> Jf k tN <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n L) <br /> 0 <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> /� f <br /> Structure Use: lea j <br /> (family home/cabin, garage, addition, etc.) on IN <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 2 I <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O a <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 m <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within Z <br /> 300 ft. o n <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m � o <br /> to 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 I <br /> dated by the owner. M a <br /> PLOT PLAN <br /> 46 Cn <br /> b0 <br /> N <br /> m y <br /> o <br /> L� I <br /> \ Z <br /> rnN � N � DDO m <br /> 9 <br /> m g. c� '-'am am <br /> P <br /> f 0 T� i <br /> m <br /> [ G) 2 i O <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know]- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- O <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 $ 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 a <br /> m mo <br /> access to the above descr' prem' s at an reasonabl im a purpose of Inspection. v $H <br /> 0 pp <br /> N u 8 <br /> SIGN HERE2 <br /> (signal u' contr tor) �1 Y M <br /> ZONING ADMINISTRATOR a <br /> TOWNSHIP PERMITS MAY BE REQUIRED NOV — I W <br /> 888888 <br />