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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z 6 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 m -� <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 Wisconsin. p J <br /> R n L ^k L rZ c O <br /> OW ER(Please Print) Contractor or Surveyor or Agent <br /> ZAddr as Address <br /> C;-/,if/�j-L Ifli/_ �_IJll.2� <br /> Clty,State,Zip ode City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary _ Camping Unit n o <br /> Privy Subdivision 0 .`.- <br /> r <br /> Structure Use: <br /> (family homabin,garage,al tio , etc.) o v J <br /> 11m <br /> Directions for plot plan drawing: yJ <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). <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 lake, t <br /> river or stream, if applicable. 1 <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. 6. Provide legal land description. n <br /> 0 <br /> PLOT PLAN3 <br /> o N <br /> c <br /> Z Q <br /> o a <br /> y <br /> 51 <br /> O <br /> t J <br /> t <br /> h I <br /> N <br /> N <br /> O <br /> N <br /> o <br /> N � <br /> A�dl <br /> r <br /> S� <br /> J m c_ m w o a cm m <br /> n Q< > > 0a-.m <br /> Ll M =;M <br /> 0 O o <br /> n O 719 <br /> 3 <br /> O p <br /> ^' O m <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m <br /> PP ( 9 Y ) Y ll <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> 'GN HERE <br /> (signs ure of owner orb ' mg contractor) date) E o E o <br /> 'G ADMINISTRATORe)rn <br /> o: o <br /> w-1 <br /> NNOiJ��Nm <br /> OWNSHIP PERMITS MAY BE REQUIRED <br /> 00000$oN <br />