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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -. 0 <br /> APPLICATION FOR — LAND USE — PERMITSIm3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w i <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 $ � <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulations oftheState of Wisconsin. w <br /> OWNER (Please Print) - Contractor or Surveyor or Agent o <br /> AddressAddress <br /> W��,�r ✓amu � �` �` <br /> City, State,Zip Code City, State,Zip Code C, \ <br /> Ar1G - kYy"t ,: <br /> Telephone Telephone (1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o o <br /> N <br /> Dwelling Addition Filling/Grading Camping Unit S A' <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o m \ <br /> Garage / <br /> Structure Use: C' ,ire, n r1i -�. n r "-� �t,rr�.�.�d.1-4-\ r <br /> 0 <br /> (family home/cabin, garage,addition,etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). X n <br /> 2. Show the location of the well (N),septic tank (ST), and drainfieid (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building � Z 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 n S2. r <br /> dated by the owner. C A� <br /> PLOT PLAN <br /> I� <br /> 0 <br /> ia' rti, TS pat< r <br /> u% <br /> 6 we I z <br /> t /ve yrs 2. <br /> a m a N a s. m <br /> _ Z <br /> 1 aZ : <br /> � Tm: m <br /> SRi 9-- O <br /> 8f e : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 j 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 m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- `�'m N <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 permit county officials charged with administering county ordinances or other authorized person to have u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 g 0 <br /> $ SAN : <br /> SIGN HERE <br /> (signat a '-"er or bui di g contractor) (date) <br /> -_ <br /> ZONING ADMINISTRATOR <br /> OWNSHIP PERMITS MAY BE REOUIRED <br /> 8888888 <br />