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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator N H Z <br /> f P <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m `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 rd Wisc n In. m <br /> L/— <br /> r �m f0 <br /> OW ER (Pleas Print ontractor or Surveyor or Agent m m <br /> Addr�ss J �( <br /> y/ ) / Address 1 �. <br /> / <br /> City Slat 7�ip C cle h �jrCity,State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Nares/ "� ./S, x.= 6 <br /> Legal Description (as Indicated oo tax(sttaa-tem6ent) 5 (1U u r -� 1/Z AcG <br /> t � o � <br /> o <br /> Permit(s) Applied for: <br /> ` <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision I 3 <br /> Garage Ll ( ` <br /> Structure Use: C P / 0 Pte. <br /> (family home/cabin, garage,addition, etc.) <br /> 0 <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). O o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show dimensions infeetofthefollowing:(a)building to all lot lines,(b)building tocenter line ofroad,(c)bullding Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. O. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed an m o <br /> dated by the owner. J C I ' <br /> PLOT PLAN vylya uT A <br /> r ----- III <br /> _oV� QrC� y 1 <br /> N <br /> V l p <br /> /'y ' a( 0 I(ST <br /> m <br /> r l <br /> y <br /> s o c T v m r^ <br /> M <br /> ... G N <br /> 0C <br /> N: m <br /> N n C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my for 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- fn m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- g m v, <br /> mation I 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- ru <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 0 u, 0 <br /> access to the abo3wdescribed premises at any reasonable time for the purpose of inspection. -n 3 g <br /> SIGN HER � '-=- - v i <br /> (s ure of owner or butiom contractor) ,t (date) <br /> ZONING ADMINISTRATOR �•e'i�z'- — ' /�� w�n <br /> TOWNSHIP PERMITS MAY BE REQUIRED ___ — g S g g g g g g y <br />