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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; T o 0 <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 y <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the — <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regula ons of the State of Wisconsin. m m <br /> In�n �i�'i2S U6C4a <br /> OW R(Please r'nt) 1. Contractor or urve or r Agent o <br /> J ca <br /> Addr�esgJt� I I Adc ss <br /> City, State, Zip Code City,State,Zip Code 1 <br /> I-;I)qa-, �- <br /> Telephone Telephone Q �- <br /> O <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). A O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 3 <br /> on 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within <br /> 300 ft. Z a <br /> 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 0 <br /> to lake, river or stream, if applicable. m , o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C UI <br /> dated by the owner. m <br /> PLOT PLAN J <br /> i 1 <br /> ° <br /> m <br /> o <br /> Z <br /> 1 <br /> o C m 0 m a nal m <br /> A D <br /> as. a <br /> < < m <br /> m o <br /> o moo : ,z 1 <br /> f ° Tom : D <br /> M <br /> N ` G) o E O <br /> $ [ a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <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 0, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> m m AQ <br /> H N 8 ; <br /> SIGN HERE `; a <br /> (signature of owner or building contractor) (date) o x <br /> ZONING ADMINISTRATOR "Tames 1" FIIanqID g <br /> TOWNSHIP PERMITS MAY BE REQUIRED n N N O N O O m <br /> 88888888m <br />