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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,N 0 o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <br /> TO THF 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 Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other app!' ble County Ordinances and th ws and regula- 3 n <br /> tion/nss of the State of Wisconsin. �/p d <br /> A r 't 4 p <br /> OWNER(Please Print) Contractor or Surydor #cen o <br /> Vier E5 <br /> n % <br /> City,Stat ,Zip Code City, State,Zip Code <br /> C� !) 4��t<-- y/ � l <br /> Telephone -relephone <br /> Emergency/Fire No.and Road Name <br /> i <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for =' O i <br /> 0 <br /> New Building �X_ Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision <br /> Structure Use: � v° ' <br /> (family home/cabin, garage,type of 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). <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 ordi- <br /> nary high water mark of 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 dated by <br /> the owner. o <br /> 3 <br /> PLOT PLAN �,(E't �( Z c <br /> �/ <br /> P n <br /> C <br /> N <br /> 1`f O <br /> � n <br /> rj <br /> C <br /> J <br /> O <br /> N <br /> - N <br /> m <br /> O <br /> 0 <br /> N <br /> 0 <br /> 0 <br /> w � <br /> lO <br /> I Z <br /> M cM.mm aacm <br /> n a< »' 0L: ' <br /> m n < - nm <br /> y' � w ppb 3 <br /> m <br /> ? 1 <br /> Np [ y <br /> G i <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 informa- o 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 n <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 d c-}ibed remises at any reason ime for the purpose of inspection. <br /> T <br /> SIGN HERE <br /> (sitVFe of er o bui/lc��ng contractor) (date) o! o <br /> ZONING ADMINISTRATOR <br /> N NOiV �� <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N til N O O N <br /> �oo oo$o <br />