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Y <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w ~, <br /> m c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the w <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. m m° <br /> a �o <br /> OWNER (Please Prim Contractor or Surveyor or Agent o <br /> z � a m <br /> Address 1 , Address <br /> City,State,Zide City,State, Zip Code <br /> 54-g3c� � <br /> TelephoneA� 3�n ` Telephone <br /> y c�.l _h <br /> Emergency/Fire No. and Road Name �) <br /> Legal Description (as Indicated on tax statement) <br /> � O <br /> Permit(s) Applied for: o <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> Z oQ. <br /> Accessory Building Sanitary Privy Subdivision ° - <br /> Garage Zelaln <br /> fiJ ts'I_ �f 1 !r�� � <br /> Structure Use: _ <br /> (family home/cabin, garage, addition, etc.) I g <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 (W),septic tank (ST),and dreinfield (DF). 3 v <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. ° <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m N <br /> dated by the owner. C <br /> PLOT PLAN (A i <br /> m � <br /> a <br /> d� <br /> N <br /> \J , <br /> O <br /> b <br /> O � <br /> ° <br /> Z <br /> is <br /> o c m m a m <br /> � Cii3m 3 <br /> M <br /> Tei M <br /> m <br /> u l 02 : O <br /> 8 . <br /> i C <br /> q\. <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- 'c a m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m a <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g w 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"' o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 52 g m . <br /> m 3 A s <br /> � �] I <br /> SIGN HERE 9 �9-F �� <br /> (signal r owner or building contractor) (date) <br /> ZONING ADMINISTRATOR ^ 8 <br /> TOWNSHIP PERMITS MAY BE REOUIRED 6 N o o m <br /> 8888 $ 8$ 8rmn <br />