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41 <br /> Burnett CoutSty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 c <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 n <br /> regulations of the State of Wisconsin. y <br /> OOpitko f8FMS SELF c o <br /> OWNER Please rim Contractor or Surveyor or Agent o m <br /> 101 raj RT ST <br /> Ad ressAMEfZofj l S4do2Z Address <br /> , W <br /> City, State, Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n L7 <br /> Permit(s) Applied for: / 0 °. <br /> 1x/ N r <br /> DwellingAddition Filling/Grading Camping Unit ° <br /> v <br /> Z p <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: <br /> (farri home/cabin, garage,adAion, etc.) <br /> � a <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <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). 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 In � <br /> measurement to the ordinary high water mark of lake,stream,or river. o a� <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. IIA O , <br /> PLOT PLAN m � :1 t <br /> J S <br /> a <br /> N <br /> �. <br /> m <br /> � O\ H <br /> Z <br /> Z <br /> 1 <br /> 0 c m m - 4 F SMo <br /> N <br /> aaiD <br /> Z os 00 SO co <br /> mo <br /> f <br /> /\ = m <br /> N � n C <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- yy!!m N O <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 25 mN <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g a 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. Iagree to permit county officials charged with administering county ordinances or other authorized person to have n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 8 a . <br /> m ' v A H f <br /> 2 m A <br /> SIGN HERE 8 <br /> ( ignature of owner or building co ra or! „ <br /> ZONING ADMINISTRATOR .C.�// <br /> TOWNSHIP PERMITS MAY BE REQUIRED2 4 N N o 6 N8 m <br />