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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co d o 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 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 Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions ofy"State of Wisconsiq„ o <br /> erornr L{�l <br /> N � <br /> OWNE (Please Pr' t Contractor or Surveyor or Agent a E <br /> /JH / IVIL <br /> Addres�J�YQ5� Address <br /> /rJ.(1 <br /> City,State,Zip Com City,State,Zip Code 7 <br /> (/ <br /> Teleppp neTelephone <br /> Emergency/FireANo. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> 0 <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> 14.w <br /> Addition Privy Moving Subdivision g <br /> Z p <br /> Structure Use: P a <br /> (family ho)Aa/cabin,garage,addition,etc.) a <br /> Directions for plot plan drawing: J <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 fot lines,(b)building to center line of road,(c)building to fake, <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 by 0 0 <br /> the owner. <br /> in v m <br /> PLOT PLAN otz a <br /> o a <br /> m Z <br /> 0 <br /> Cl <br /> m <br /> y <br /> R <br /> 0 <br /> o <br /> 711 <br /> m <br /> N_ <br /> A I ` <br /> Z <br /> o <br /> BIdq , <br /> y MV(nr DDOo� <br /> N Or<c .M 3 0 a c m <br /> m a� am »am <br /> v' S` i mcmom3 <br /> o-; w c m _ <br /> o a: fDQ ; 1 <br /> [ m m: `: A <br /> a—, <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a ; <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- �o fD <br /> 9 P 9 P Y 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 ' o m a <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. <br /> m 3 Ai <br /> SIGN HERE <br /> N O; <br /> V O; <br /> (siga of owner 'Iding contractor) ( ate) o: <br /> o: <br /> ZONING ADMINISTRATOR <br /> �Npp000m <br /> TOWNSHIP PERMITS MAY BE REQUIRED ai <br /> 0000 <br />