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Burnett Cdunty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 a o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H o <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 <br /> regulations of the State of Wisconsin. H m <br /> DAL As BLAc.1(8yRW SAIF a ' g <br /> OW Please Pn ) Contractor or Surveyor or Agent 'm <br /> Address Address <br /> SIRS . Wi- SSS-77- - <br /> City, State, Zip'Code City, State,Zip Code <br /> r <br /> Telephone Telephone i r <br /> v <br /> , <br /> Emergency/Fire No. and Road Name Uj <br /> Legal Description (as Indicated on tax statement) <br /> o <br /> Permit(s) Applied for: �- <br /> m R <br /> Dwelling Addition Filling/Grading o <br /> Camping Unit � <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° $ <br /> Garage <br /> Structure Use: rCCWWt;; <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 2 P <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (DF). on 3 v, <br /> 3. Show dimensions infeet of thefollowing:(a) buildingto all lot lines,(b)building to center line of road,(c)building 10 <br /> Z Q <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 H mZ <br /> dated by the owner. C I O I ff1 M( <br /> PLOT PLAN (A ' t <br /> m <br /> m <br /> vc n <br /> °P I(j1 <br /> o <br /> Z <br /> m, 9g � ?nN "_ M <br /> 00 os a <br /> o f 0 T� 1 <br /> In <br /> � � I O <br /> 8s <br /> a <br /> � <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o I m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the <br /> detail and accuracy of all informs- w m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m u' <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 A 8 <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- N <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. n <br /> 18 0 <br /> r 3 <br /> m v n a <br /> q <br /> SIGN HERE N4! <br /> (si nature of owner or building colo (date) o <br /> ZONING ADMINISTRATOR <br /> M � MHe m <br /> TOWNSHIP PERMI S MAY BE REQUIRED N cob" m <br /> 8 888rmn <br />