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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ' 0 0 <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 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 applicalb�"ourtty Ordinances and the laws and - n <br /> regulations of the State of Wisconsin. j m <br /> Z42,4 5CA <br /> �OWNE lease Pri ) Co actor or rveyor or A rtt- m <br /> /3S �/�r,� <br /> Ad 17 <br /> �/7f��1/��. dress <br /> City,S�Z� ity, State,Zip C e y <br /> Telephone Telephone I <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> C) C> <br /> Permit(s)Applied for: �- <br /> N ^ r <br /> Dwelling Addition Filling/Grading Camping Unit 0 V i <br /> z a <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: / o <br /> (famiy ome/cabin, gar e,addition, ) <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 (VI),septic tank(ST),and dralntleld (DF). o 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 <br /> measurement to the ordinary high water mark of lake,stream,or river. P I� <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and w ILC <br /> dated by the owner. C 0 <br /> d <br /> PLOT PLAN m Lei <br /> I <br /> 1 rn <br /> IV <br /> V ? <br /> m <br /> o � <br /> z <br /> a <br /> i; <br /> a M <br /> a mZ ,Zuo `im 3 <br /> Z <br /> rn n c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- 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- a O <br /> tion contained In this application(including any accompanying schedule)and I further declare that I recognize that this infor- m rn <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ m g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 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 $ g <br /> A 3 n N <br /> SIGN HERE 11f <br /> (signature of owner or building contractor/) 'is) c'. <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY E REQUIRED c,o 8 r, <br /> $ $ $ $ $ 8u <br />