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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn -10 o a <br /> -APPLICATION FOR — LAND USE — PERMITS3 <br /> v a <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 `m (� <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulatio of the St a of Wisconsin. H o v 1 <br /> irL ,5f Cl��ser a = rb o <br /> OWNER (Please P ' t /� Contractor or Surveyor or Agent o <br /> Address Address C � <br /> 1Ztnk1' /V1 <br /> TelepTelephone <br /> City, State, Code City,State,Zip Code I-) <br /> =) �(� - /��D SO <br /> F �h ne 71-2/ LX_/, /'CZr Q 9 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) v / <br /> Permit(s) Applied for: o <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage r Structure Use: -- - r <br /> 0 <br /> (family ho /cabin, gara , addition, etc.) O 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). 21 O <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 <br /> 300 ft. an z <br /> P <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road, (c)building 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. m W <br /> PLOT PLANcol <br /> e <br /> I <br /> Y <br /> t ur <br /> o <br /> N_ <br /> (�t: 0 4/r� <br /> 1 <br /> O <br /> I <br /> 2 <br /> s <br /> o ink w w Da F m <br /> 00 no z N O N `° <br /> O F J [ ° M <br /> In <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- m <br /> 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- <br /> N 0 N <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- o m u <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have vI <br /> access to the above described premises at any reasonable time for the purpose of inspection. Vv 8 0 <br /> m 3 <br /> N U A N <br /> `� 7 A m 8 <br /> SIGN HERE <br /> (signat owner r uilding contractor) (date) <br /> o . a <br /> ZONING ADMINISTRATOR " 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED w OuNo o m <br /> 888rmn <br />