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(Uj SC -i S;.,1 rw r <br /> Burnett County T410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w - 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> d O <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 o m <br /> Burnet,County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulayons of the State of Wisconsin. H m <br /> la-�h I�' n N�� h M�� n v f <br /> la <br /> OWNER (Please Print Contractor or Surveyor or Agent o 'm <br /> m <br /> Addre�s. r' .W Address <br /> City, State, Zip Code City, State, Zip Code <br /> Telephone �— Telephone I_ <br /> Emergency/Fire No. and Road Name J� <br /> Legal Description (as Indicated on tax statement) <br /> n G> <br /> 0 <br /> Permit(s) Applied for: �- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit ° g J <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision } <br /> Garage <br /> I <br /> Structure Use: o <br /> (family ome/cabin, rage, addition, etc.) <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). 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 0 m <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream-if withinon <br /> 300 ft. o n <br /> 4. Shaw dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building C H <br /> to lake, river or stream, if applicable. m ° <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. m Y J <br /> PLOT PLAN a <br /> 1 y <br /> m <br /> m <br /> I� <br /> o <br /> w <br /> z <br /> In <br /> '^ < 5 : � H O . ms3 <br /> z mo m ,Z : 1 <br /> O £ 21 y <br /> m <br /> rgi € m a <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- a(w o <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ 'm N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have na o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ m <br /> T 3 n <br /> v <br /> SIGN HERE <br /> V n : <br /> (signature of owner or IaAilding contractor) 1 (date) o x <br /> ZONING ADMINISTRATOR —, TAM&S I RNO 6 9A) <br /> TOWNSHIP PERMITS MAY BE REQUIRED U"�n N �� o o 8 m <br /> 88888888vi <br />