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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (m A o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3_ - <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and '2 ui <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 /> regulatio of the State of Wisconsin. m _° <br /> C a O <br /> f <br /> OWNER (Please rint) , Contractor or Surveyor or Agent o � <br /> Addresy/n��� � /X, �� Address <br /> City, State,Zip Cgoe (� City,State,Zip Code <br /> Telephone Telephone <br /> Emergent /Fire d Id Na <br /> 127 fFVr417it1 *:Y <br /> Legal Description (as Indicated on tax statement) 4 <br /> n O (10Permits)Applied for: j <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> Z <br /> v <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: <br /> (family home/cabin,6arage, addition, c.) o <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). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield 1 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 P <br /> 300 ft. an z <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building C o a <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 <br /> dated by the owner. to <br /> M <br /> PLOT PLAN <br /> G <br /> I <br /> h ,� c <br /> m <br /> o <br /> cx; <br /> z <br /> o c m m a O V <br /> oDa� daNae� M <br /> < ` m o <br /> 0 0 . <br /> m <br /> cd'i, o O <br /> g ac : C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o N m ZM <br /> m <br /> edge and belief it is[rue,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- v,m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 0 N <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m g <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 N <br /> access to the above described premises at any reasonable time for the purpose of inspection. r 3 g <br /> 3 A u <br /> SIGN HERE <br /> (sig a of owne,rr building contractor) (date) a <br /> g <br /> ✓✓%%_�/V o : s : <br /> ZONING ADMINISTRATOR <br /> ` 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED " <br /> N N O N <br /> �$ $ $ $ $ In <br />