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Burnett County'7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w ; -.c <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for 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 <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a <br /> �regyI tions of the State of Wis onsin. y m° <br /> o6" 1q. 2,")� � l��2 R y � / ND�2 a S 0 <br /> WNkj (Please Print) yy/ Contractor or Survey r or Agent o �m <br /> L ea 4 % Y// l�L �e m <br /> Address Address <br /> City, to Zip CodCity, StateZip Code <br /> , r <br /> 1S,4Se 7 2 // .S'y�93 ueK ; fir r <br /> I elephon�_ Telephone Z _ �� <br /> 3 <br /> Emerge y/F,ir an gall arae <br /> Legal Description(Description (as indicated on tax statement) a <br /> n <br /> Permit(s) Applied for: � <br /> ] <br /> Dwelling Addition Filling/Grading Camping Unit S o <br /> v <br /> z o <br /> Accessory Building Sanitary PrivySubdivision ° e <br /> m <br /> Garage <br /> Structure Use: E4FM U)[ q <br /> (family horde/cabin,garage, addition, etc.) o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) Q <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M 0 <br /> 2. Show the location of the well (W),septic tank (ST),and dreinfield (DF). 00 <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building ' c <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and y <br /> dated by the owner. M o <br /> C <br /> PLOT PLAN to 1 <br /> m <br /> see- u - VC c. <br /> m <br /> n <br /> 0 <br /> Il] <br /> O A <br /> J <br /> O y <br /> N <br /> -ni <br /> ( z <br /> mb <br /> 695S 0 o a m m a m <br /> / m <br /> ]sa a p <br /> = < ` : H C <br /> Z D <br /> o m <br /> P F r Mm <br /> = m <br /> 8 ` i A A <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o am <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- dt m H O <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. 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 pe county officials chargaId with administering county ordinances or other authorized person to have i iu <br /> access to the abov desc ibed premises at a r asonable time for the purpose of inspection. : m 8 <br /> m A N <br /> m : m <br /> SIGN HERE <br /> (si e f o r or building contractor) (date) <br /> ZONING ADMINISTRATOR � !�+%' - ) ` ' 8 ' <br /> it N <br /> TOWNSHIP PERMITS MAYBE REOUIRED '' 5 (r�r� N$N o o m <br /> b` H��7tG 88898888u) <br />