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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n (— <br /> tions of the Sjjtate of Wisconsin. 1!1 <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> 2S7tl <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code rJ <br /> Telephone Telephone ,--� <br /> CL <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax stat ent) <br /> 0 <br /> Permit(s)Applied for. n o <br /> New Building X Sanitary Filling/Grading Camping Unit 3 .`.- <br /> m <br /> Addition Privy Moving Subdivision o <br /> z <br /> v <br /> Structure Use: <br /> (family home/cabin, garage, addition,etc.) (n <br /> c r <br /> Directions for plot plan drawing: � 1 <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). .� o <br /> 2. Show the location of the well (W), septic tank(ST), and drainfield (DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft.and the location of any river or stream-if within 300 ft. <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> 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 dated byO O <br /> the owner. <br /> ON 3 m <br /> PLOT PLAN 7I Z v <br /> o a n <br /> I� c ; �y <br /> Ojel <br /> 5� I N <br /> o <br /> i; <br /> j071 <br /> c <br /> S <br /> r 7 Z <br /> pp) + <br /> m NvmrDamm <br /> _. c �.� mmncm <br /> f1�oor Yoo ------ <br /> ' " a <br /> wi � mm �rp � <br /> 'll <br /> E 9 f»l; <br /> =c m <br /> LA g <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it Is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 0;-- m <br /> tion contained In this application(Including any accompanying schedule)and I further declare that I recognize that this infor- <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- $a 8 i <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. E Oro <br /> m ` 3 <br /> SIGN HERE <br /> ( ign)lure of own building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> rn <br /> '• E i <br /> to in�+iw iw win <br /> rooro�Pbm <br /> TOWNSHIP PERMITS MAY BE REQUIREDo oVm <br />