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Burnett C'Ilirnty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 3 £ ✓ P <br /> APPLICATION FOR — LAND USE — PERMITS - o <br /> N <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the '^ a <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 W� consin. w <br /> m O <br /> a f <br /> OWNER ( lease Prin Contractor or Surveyor orOG11K m <br /> AYe 1 ati <br /> CCDTIr� ➢ Cvnarrnu <br /> lGl <br /> Address Address HCR 59, Box 478d <br /> aS tnbovJ� <br /> City, State, - Co, Q City,State,Zip r t <br /> 9�onctr\�, �; s�801 p15M7482 <br /> TelephohO_ Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n o Z <br /> Permit(s) Applied for: H <br /> _ r <br /> 0 <br /> Dwelling Addition 5rvy <br /> ling/Grading Camping Unit 'QQQ�QQQ° <br /> Accessory Building anitary - Subdivision ° 3 <br /> Garage <br /> Structure Use: ) ' ` <br /> (family home/cabin, garage,addition, etc.) <br /> � s <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) n D <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O 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 Z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. ° n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m k o <br /> dated by the owner. C �- <br /> (� ) 0 <br /> PLOT PLAN j <br /> L �r <br /> LAo <br /> I 4; <br /> Z <br /> n o c m m o a o <br /> N N 1 <br /> o F on T U) <br /> M <br /> c <br /> g : n � <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i 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- fn m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 2S m <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ '? $ <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- I <br /> plication.I agr a to permit county offi s charged with administering county ordinances or other authorized person to have m g o <br /> access to the ove scribed premi at any reasonable time for the purpose of inspection. ro v h q , <br /> [ m rt £ <br /> 10— oi- 7 " 2S <br /> SIGN HERE (date) ' <br /> (si a re of own o till co racto 1 o ? <br /> --� 7 $ <br /> ZONING ADMINISTRATOR <br /> q NHNH �, <br /> TOW HIP PERMITS MAY BE REQUIRED 8 <br /> 8898 m <br /> bl <br />