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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 - PERMITS3. <br /> m Q <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 '^ m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a - <br /> regulations of the State of Wisconsin. <br /> JI?Ht4 YA(A EICH-TF_nl 3r2 <br /> Contractor or Surveyor or Agent o mOWI! PrtRu)dG <br /> ST• 1� <br /> AddressW OA ' Address 0 1 <br /> City,'State,Zip Code City, State,Zip Code <br /> 1012 239 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name �3 <br /> Legal Description (as indicated on tax statement) o <br /> � lLJ <br /> Permit(s) Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> } <br /> Garage <br /> I f ' ' "' '�//d �\ <br /> Structure Use: ��,v n/ <br /> (family home/cabin, garage, ddrtion, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <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). o o m <br /> 3. Show dimensions infeet of thefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building Z c <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 m <br /> dated by the owner. C > > <br /> PLOT PLAN m 4, S <br /> 9j <br /> a <br /> ] <br /> N <br /> ] <br /> m <br /> o <br /> N <br /> o c � ro m o a y m <br /> m. Roamamy <br /> m <br /> $ n � C <br /> A : rn <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 0 : m <br /> informs- m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all -' w N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m 0 : <br /> mation I 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 /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have n u' o : <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ <br /> m 3 <br /> SIGN HERE <br /> (sig ature of owner or building contrac (date <br /> $ ' <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N a N o o S$ m <br /> 8888$ 88 $ N <br />