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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (nm O o <br /> APPLICATION FOR — LAND USE — PERMITS 3. - <br /> V <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 /> riave � r <br /> f l /f, S f n. , a f <br /> OWNER (Please Pri t) Contractor or Surveyor or Agent o <br /> �1a9 i 9 �fi 4Z, 1,,I' m <br /> Addr�s Address <br /> R'I� <br /> City, State, Zip Code City,State,Zip Code <br /> boy—';?'Qz - &'4V6 1 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> � t7 <br /> Permit(s)Applied for: o ° JZ_ <br /> 0 <br /> r <br /> Dwelling Additions Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: ` azor l nnncl - <br /> o <br /> family home/cabin,garage,addition, 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). <br /> 2. Show the location of the well (MI),septic tank(ST),and dralnfield (DF). 3 rn <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building .E z <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. it separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. <br /> C I <br /> PLOT PLAN <br /> 1 <br /> 0 <br /> 0 <br /> N <br /> � ` o <br /> N <br /> /U0 ytise �r+f`t , l i <br /> Ao <br /> � l <br /> c� <br /> /00, le <br /> o c m0 30 <br /> m o n g m <br /> A. Dii� a nN a = a <br /> 21 M <br /> 1 4.P Q or— ��i, ' c : E O <br /> 9-/ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o [ 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- yy!! m« O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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. I i go 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have n N o <br /> access to the above described premises at any re onabl time for the purpose of inspection. $ <br /> A s : <br /> w <br /> M N <br /> SIGN HERE <br /> (sign re owner bull ontractor) (date) Qt [ o ? <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY SE REQUIRED <br /> 88888888u <br />