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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO TFIE,ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and ie <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the t <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. o <br /> �Ili.►(iNl SN���S SE�E <br /> OV(N1PP�ase rl�n� Contractor or Surveyor or Agent o <br /> Address <br /> ��� p Address <br /> City, State, Zip Code City,State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name ,I <br /> Legal Description (as Indicated on tax statement) a <br /> Permit(s) Applied for: ^ o <br /> o < <br /> Dwelling _ <br /> Addition Filling/Grading Camping Unit o <br /> Accessory Building Sanitary Privy X Subdivision o <br /> Garage } <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). M 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drafnflaid (DF). C 3 <br /> 0111 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)buildingZ <br /> measurement to the ordinary high water mark of lake, stream,or river. � o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H <br /> dated by the owner. m o` <br /> PLOT PLAN tCp <br /> m �.J <br /> A�tflcN�r� I � <br /> i <br /> O <br /> ? �J <br /> m <br /> o <br /> I <br /> � Z <br /> m o c m d a F Ian <br /> n <br /> m - a� '- n m a � a <br /> m < . " c H o 9 <br /> o 0 Tom: M <br /> In <br /> 8 c : <br /> I 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 I am responsible for the detail and accuracy of all informs- O <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 A g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ^> <br /> access to the above described premises at any reasonable time for the purpose of inspection. m N 4 <br /> r 3 <br /> 80 <br /> m v A m <br /> t f$ a2 • 0g <br /> SIGN HERE a <br /> (signature of owner or buildin ntrac d - �'' n <br /> o ; x <br /> ZONING ADMINISTRATOR 8 ' <br /> TOWNSHIP PE MITS MAY BE REQUIRED N a N o o x m <br /> m <br /> 888888rn <br />