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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m a o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Q <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. w d <br /> &I,Egf- I7ETU50N SELF a <br /> OW (P gSe PriContractor or Surveyor or Agent v <br /> 2 ��S11�G�1L 12D - <br /> Uress Address m <br /> E7951flz . W i . 51893 � <br /> C' State,Zi e City,State,Zip Code <br /> (CC,�- Li Is8 m <br /> Telephone Telephone 1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: 0 C. <br /> ° <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> U1 <br /> Garage I O 00 <br /> Structure Use: (~ t� o <br /> (family home/cabin,garage, add ion, 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 drainfleid (DF). 0391 <br /> m <br /> 3. Show dimensions In feet ofthe following:(a)building to all lot lines,(b)buildIngto center line of road,(c)building 0 Z ( n <br /> measurement to the ordinary high water mark of lake,stream,or river. o <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and y <br /> dated by the owner. C <br /> PLOT PLAN w <br /> rn <br /> C�A E0 ) <br /> N <br /> J o <br /> O <br /> m <br /> O � <br /> w e II}�r <br /> °70 I <br /> Q <br /> Z <br /> 1 � <br /> A o c T NN d - a W rro <br /> �^ <_ zZino >> 3 <br /> Z ¢ a a .Z : . 1 <br /> O 2 O ; Tln; M <br /> �ii t7 O <br /> m � C <br /> g A\ : <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- g : ym <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- a o O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g 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 ct v <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 8 9 <br /> me $ A m <br /> a : <br /> y u <br /> SIGN HERE (signature'of owner or building contractor) <br /> - (date) o s i <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REOUIRE11 JUL ( Q I191 8 8 8 8 8 8 8 8 y <br /> 11L <br />