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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratora o <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d O <br /> TO THE'ZbNING 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 0 r, <br /> Burnett County Land Use Ordinance,Sanitation )ation Code, and with all other applicable County Ordinances and the laws and 3 a V <br /> regulations of the State of Wisconsin. 5 <br /> OWNER (Please Pri t) Contractor or Surveyor or Agent o <br /> C2 C N - <br /> Add s Address <br /> City, State, Zip CocI6 City, State,Zip Code <br /> ,- s� <br /> Telephone Telephone <br /> 12s� - 33 �/ <br /> Emergepcy/Fiire No. and RRoa ame <br /> Legal D6criptltlon (as Ind(sated on tax statement) <br /> c <br /> Permit(s) Applied for: a °- <br /> Dwelling Addition Filling/Grading Camping Unit ° C� <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> StructureUse: i <br /> (family ome/cabin, garage, addition, etc.) 'n <br /> DIRECTIONS FOR PLOT PLAN DRAWING: �5 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST), and drainfleld (DF). C 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 o <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 q a <br /> to lake, river or stream, if applicable. m CK� <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 II <br /> dated by the owner. m p <br /> PLOT PLAN C� <br /> I <br /> I <br /> 0 <br /> m <br /> 43 <br /> I <br /> o <br /> n <br /> Z <br /> 31 <br /> I <br /> 0 O C N Nr n d :E m <br /> a <br /> 2 , o m <br /> o f TN p <br /> M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <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 informa- e. m v+ 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 8 m 8 <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. m g <br /> N A m <br /> SIGN HERE: �'� /e /`, _ qo H ` N 8 <br /> (sire of o er r b 'Iding contractor) (date)FIT <br /> o s <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED o m <br /> 8 888 (mn <br />