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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'o o a <br /> APPLICATION FOR — LAND USE — PERMITS a 3. <br /> s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 �' <br /> 0 <br /> regulations of the State of Wisconsin. w °= <br /> 1:27 f'74 �� S l� Q�S� LL- __ n E <br /> OWNER ease Print) Contractor or Surveyor or Agent m m <br /> t' V Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> v <br /> Emergency/Fire No. and Road Name <br /> -A e ff _e, 41C4 r rA A <br /> Legal Description (as Indicated on tax statement) S,F( , )7 7-al)o yo A/ 1\ A/B, / 6 W, <br /> Permit(s)Applied for: <br /> y <br /> S = <br /> Dwelling Addition Filling/Grading Camping Unit Q <br /> � <br /> Z o <br /> Accessory Building SanitaryPrivy Subdivision o } <br /> Garage <br /> a,* <br /> 1 �( <br /> Structure Use: SC r 4,41 d( a,*'y S `ya I� /i` l <br /> (family home/cabin,garage,addition, etc.) <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). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (DF). 3 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building q - Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and o j <br /> dated by the owner. C i <br /> PLOT P N - /7- <br /> FreAlch iZOdct 111 <br /> in <br /> 0 I` <br /> I_ <br /> E' <br /> I Z <br /> IIN� <br /> Q { <br /> L <br /> 4 <br /> '° oa ,.mmaa [ <br /> A g <br /> c ' a ry <br /> 'Z m o 0. ,'o <br /> N 0 <br /> o <br /> $ n <br /> 1 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 1 am responsible for the detail and accuracy of all informs- G7, ' " a Eat y! <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 2S i7 <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $m $ <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 /> inistering county ordinances or other authorized person to have <br /> plication.I agree to permit county officials charged with admm 3 $ <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> H i D i <br /> SIGN HEREdate) ' <br /> 'nature ner or building contractor) o ? <br /> k89999999 <br /> ZONING ADMINISTRATORan TOWNSHIP PERMITS MAY BE REQUIRED <br />