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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m a o 0 <br /> APPLICATION FOR — LAND USE — PERMITS m 3 <br /> ° <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � y <br /> U) <br /> located as c:iown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the q 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. m m <br /> (� m <br /> f <br /> OWN R Please Pnr)t) 1 Contractor or Surveyor or Agent 9 <br /> f2elAd re Address <br /> City, State, Zip Cod City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) ° -y- <br /> n_ <br /> Permit(s)Applied for: 0 o <br /> o <. <br /> Dwelling — Addition Filling/Grading Camping Unit g <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: L " 0 <br /> (fa ily home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O n <br /> 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). � a v , <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within Z `v <br /> 300 ft. o n <br /> 4. Show dimensions infeet 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 /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 0 <br /> dated by the owner. M S <br /> PLOT PLAN r� <br /> i ` t1 <br /> 1 m <br /> m <br /> 0 <br /> 0 <br /> elf <br /> o I(� <br /> o � <br /> w <br /> M 0 c m m o a V m <br /> m - °- 1 M <br /> M <0 : � m 000. . 3 <br /> 00 0 <br /> F T m a <br /> G) � O <br /> 8 <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o , 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- w a N O <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- 0 N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ m $ <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 $ <br /> m A m <br /> H x <br /> SIGN HERE <br /> (signature ne ntractor) hr t i o E x <br /> 8 i <br /> ZONING ADMINISTRATOR �q <br /> NNON�N ^ <br /> T WNMAY 241 91SHIP PERMITS MAY BE REOU <br /> 888888 , <br />