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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> a o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 1D <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. H m <br /> N �^ <br /> o <br /> n 5 <br /> OWN€ (Please Print) Contractor or Surveyor or Agent <br /> , <br /> it i y >>)t i l wl c <br /> Address Address 1 <br /> Ciry,L' IJState,Zip Code City,State,Zip Code <br /> Telephone Telephone C> p 1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> c� <br /> Permit(s) Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit <br /> T l <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> ''`^�� ��I � p C L c I^ <br /> Structure Use: 1 W61 �r�A F7y�fll LAR r �Z(�S tC�/Yl <br /> (family home/cabin, garage, addition, etc.) <br /> � o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <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 drainfiaid (DF). 3 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line orf road,(c)building Z v <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 m H <br /> dated by the owner. C <br /> PLOT PLAIj "� <.K- 7s/ 111111 17' Z <br /> rn <br /> O y <br /> N <br /> i <br /> Z <br /> 1 <br /> o < < ,2mo3ro <br /> 1 <br /> M <br /> m <br /> [ n � <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 ° m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informa- w m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i 8 n N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g A $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- f.; N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have O ut o <br /> access to the above described premises at any reasonable time for the purpose of inspection. a 8 A <br /> D A w ' <br /> SIGN HERE 36 IZ OF N <br /> (signature of o r or bng tr tor) date) o s <br /> ZONING ADMINISTRATOR <br /> N W <br /> T NSHIP PERMITS MAY BE REQUIRED U" rn 00 <br /> 888 88 <br /> CSC IAC. Ser)T q- a 1- <br />