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&a c�))-np <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d A a o <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 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 c, <br /> regulations of the State of Wisconsin. <br /> -• f <br /> OW40R Plea a Pr'nt Contra for or Surveyor or Agent o <br /> Add% C V Address , r <br /> City, State, Zip Code city, S te, Ip Coade <br /> - � <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> � G> <br /> 0 <br /> Permit(s) Applied for: <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> 2 0 <br /> Accessory Building Sanitary Privy Subdivision o } <br /> Garage <br /> Structure Use: o <br /> (family home/cabin, garage, 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). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 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 <br /> 1I z c <br /> 300 ft. ° 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 m o <br /> to lake, river or stream, if applicable. 0 <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andC I <br /> dated by the owner, 1A (0 <br /> PLOT PLAN <br /> r e <br /> aCNJ � ��f I I �• <br /> ""„ LIl <br /> m <br /> J <br /> o <br /> D <br /> I <br /> c Dai aw 3 _ 9 <br /> fes : Tm <br /> = i m m <br /> g <br /> n ; C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- e w 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- www <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. 18 <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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> O O : <br /> access to the above described premises at any reasonable time for the purpose of inspection. w 8 m <br /> m V A N <br /> lD N <br /> H i N <br /> SIGN HERE <br /> (signature of_owner o building contractor) (date) o x <br /> ZONING ADMINISTRATOR <br /> wwHwwww <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N N O O O m <br /> $ 88 $ $ 888rmn <br />