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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorw o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 0 3 <br /> C� <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � w <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 a <br /> regulations of the State of Wisconsin. H m <br /> 6AIZ4 WWW_ S i:I F a f <br /> L�rIR (� Prin I L' Contractor or Surveyor or Agent e <br /> —t37 <br /> A, �.51� Address J n <br /> I <br /> City, State, Zip Code City,State,Zip Code j <br /> Telephone Telephone ! —� <br /> i) <br /> Emergency/Fire No. and Road Name - <br /> Legal Description (as indicated on tax statement) o <br /> � ct <br /> Permit(s) Applied for: 0 o <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o (� <br /> Accessory Building Sanitary Privy Subdivision ° z <br /> Garage <br /> Structure Use: <br /> 0 <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). M 0 <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 p 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 <br /> to lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. m IN <br /> PLOT PLAN <br /> f <br /> 4 <br /> U' <br /> J � <br /> J <br /> O � <br /> w / <br /> t <br /> J 9 <br /> i <br /> m0Cm� � ag � <br /> 0m. Da'� aaw = 9 <br /> z <. m' ? 0030 3 <br /> o On ,2 ` <br /> T n m <br /> �'_ o <br /> i mei c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- A, g : m <br /> accuracy of all informs- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ; 9S�25 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ <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- w <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 g <br /> I , A <br /> m w 8 <br /> SIGN HERE -30 <br /> (sighature of owner or building contracto (date c x <br /> ZONING ADMINISTRATOR / e 8 <br /> f <br /> TOWNSHIP PERMITS MA BE REQUIRED G N N ,8. <br /> 88 $ ,88 $ y <br />