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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d <br /> TC .-HE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> C <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. <br /> nB :P T GAJ P V/ItFir�e _ g �F <br /> 0 R(Please r' Contractor or Surveyor or Agent o <br /> / '7G� f1"4TN ,4VE iV f m <br /> Atltlr s Address ` <br /> hook �PAo�o s. /YIN 55533 <br /> —Ci Stale ZipCodeT City,State,Zip Code 1st-2- 330 3z7 <br /> Tele hone Telephone <br /> �R19 STU$,B iPDA1) a6VIL S kA,<E I.U�BS7F.E'� <br /> Emergency/Fire No. and Road Name II <br /> Legal Description (as Indicated on tax statement) q <br /> ct <br /> Permit(s) Applied for: 0 0 <br /> Dwelling Addition Filling/Grading Camping Unit S ° <br /> v <br /> Accessory Building Sanitary rivy Subdivision m <br /> Garage <br /> �a r <br /> Structure Use: � r- <br /> (family home/cabin,garage,addition, etc.) I e <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <br /> X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 02 <br /> 2. Show the location of the well (W),septic tank (ST), and draiMield (DF). 3 <br /> 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 Z o <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. C p <br /> PLOT PLAN (A <br /> Ifcn <br /> I o <br /> o <br /> m <br /> r <br /> Z <br /> I <br /> m 0 m or o n £ m <br /> �. 7o a•� 'saN sora <br /> < Z c o > > �_ <br /> P F O TZ M <br /> M <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m m ' 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m g <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 ut <br /> access to the above described premises at any reasonable time for the purpose of inspection. r 3 89 <br /> ''/ Am : <br /> SIGN HERE—Z <br /> M: m <br /> (signature of own r buildi cpKi rr (date) n <br /> ZONING ADMINISTRATOR <br /> N <br /> TOWNSHIP PE ITS MAY BE REQUIREDN 8 0 :0 :0 : <br /> o: m <br /> N N <br /> 88888888 ) <br />