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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 00 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d o <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 Co <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> C , <br /> ow <br /> mw <br /> ,f <br /> OW Panb ContooS orA j"ey A- <br /> Addre � <br /> Adtlres ( <br /> 11PJ" W 4901 <br /> City, State, Zio Co ) City, State,Zip Code ) <br /> � Ci 'r), I�I . A - n <br /> Telephne Telephone <br /> Emergency/Fire No. And Road Name r� <br /> Legal Description (as indicated on tax statement) ° ` c' <br /> n Q <br /> Permit(s) Applied for: 0 0 <br /> o �- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P a <br /> Garage <br /> Structure Use: <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). <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 v 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. f11 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and CM <br /> dated by the owner. m <br /> PLOT PLAN <br /> Sem eon _ <br /> ul <br /> /� O <br /> q�— Ul/ o <br /> a � <br /> s � <br /> O � <br /> w <br /> .�. IILNIryT <br /> Z <br /> 9 <br /> o c T m m o a g m <br /> 9 C < •Z N O J m <br /> = » ' i m <br /> l ` GIS l 0 <br /> C <br /> I declare that this application(including any accomparfying 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- "c <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. $ $ <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 O o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 $ 0 <br /> n <br /> � V n N <br /> w N <br /> H T <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) x, <br /> ZONING ADMINISTRATOR FATTIES t' �RnIIEH1V g <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIREDN N N f N N w H m <br /> $ uioo � m <br /> 888 CO <br />