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Burnett County 7410Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) 'a a c <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> 0 <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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 k t <br /> regulations of the State of Wiscogsin. V m <br /> iZ �rzr ck % "J/4n/ o <br /> OYyN�R(P.Iga e P ) �COntractof or Surveyor or Agent o � <br /> aAl01P/a <br /> A dr s m — <br /> ��[_ ,-iL Address <br /> Cilt S('ee,}Zipo dC(eg`1 J City, State,Zip Code <br /> Tel hone <br /> Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> n <br /> Permit(s) Applied for: o o <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° a <br /> Garage <br /> Structure Use: <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 (W),septic tank (ST), and drainflaid (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 p <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 <br /> dated by the owner. <br /> PLOT PLAN <br /> m <br /> 01 <br /> to <br /> O <br /> yl � <br /> 0 ?ki <br /> m <br /> v � <br /> N <br /> Z <br /> a o c <� m m o a F rill <br /> 6'G G. 002 2 31 <br /> Z m p <br /> P f s 21 a <br /> o <br /> C <br /> 8 [ , _ <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S ; 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. m m <br /> O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit.1. m <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. 8 <br /> m <br /> _ A E <br /> IIQASIGN HERE -C-2 � <br /> ,r' (signature o n b ding contractor) (date) �� <br /> ,� .� v ) f�'1 8 <br /> ZONING A TRATOR _ <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8 9 m <br /> 888 $8888 vi <br />