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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m p <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the R <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and n <br /> regulations of the State of Wisconsin. m ° <br /> 1 <br /> tc�waril l� . I�� mn,� tom v(�f��Jl a m o <br /> F <br /> OWT (PI ase Print Contractor or Surveyor or Agent 'o <br /> Address __ Address. <br /> F A I i i�! ' :�r 1,e,I <br /> City, State, Zip Cone City, State, Zip Code <br /> Tele hone Telephone <br /> PJ <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o Z <br /> ct <br /> Permits) Applied for: o °. <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit o o <br /> T <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: r <br /> 0 <br /> (family home/cabin,garage, addition, etc.) � <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). n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 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 c <br /> 300 ft. o a <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building s <br /> N <br /> to lake, river or stream, if applicable. M � <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. (A <br /> PLOT PLAN <br /> N I Yom, <br /> J j <br /> m <br /> 0 � <br /> r 1 <br /> 1 D <br /> I <br /> G N y W r D D <br /> c: <br /> o � m 3 <br /> Z o ZQ 1 <br /> m <br /> 8 p c C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- a yf�! w wa O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue as permit. 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- lE N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ,,, <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m 8 0o <br /> A <br /> m V H <br /> {p N pA <br /> N H 8 <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) 43 <br /> Q r ' <br /> ZONING ADMINISTRATOR Jr+l---F`, <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 88888888vi <br />