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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITSW ' <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and A c ti <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 <br /> regulations of the State of Wisconsin. w o <br /> TIOn wc� k 4�S ov. a Q, o <br /> OWN R(Please Print) Contractor or Surveyor or Agent <br /> l�ro7 S+7 St _ <br /> Address , Address <br /> /,, '�w5 s," La/, S�F6U t <br /> City�Vp Code F2 _ 324 <br /> City, State, Zip Code L q <br /> Telephone Telephone $ <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> � L7 <br /> Permit0 <br /> Permit(s) Applied for: o < <br /> Dwelling Addition Filling/Grading Camping Unit o g <br /> z <br /> v � <br /> Accessory Building Sanitary _ Privy Subdivision ° m <br /> Garage <br /> Structure Use: <br /> (family home/cabin,darage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C � + <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). 0 3 O <br /> 3. Show dimensions infeet ofthefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building 11 z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> n v j <br /> dated by the owner. C <br /> PLOT PLAN M <br /> i� <br /> N <br /> c <br /> o � � <br /> n LL_ <br /> Vj <br /> 'G <br /> Z <br /> f, X <br /> f <br /> mo c M. m d a F In <br /> m. Dnp � aN aA M <br /> 2 m o m oDo <br /> : 1 <br /> P sem : Tmi a <br /> iE� In <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o A a <br /> In <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- „ m„ : O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- :) v fib" m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 m g <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 agr a to permit county officials charged with administering county ordinances or other authorized person to have t7 �j o <br /> access to the bove describe premises at any reasonable time for the purpos of inspection. m3 8 m <br /> n : <br /> j D L A <br /> SIGN HERE � H n <br /> (signatur6'of owner or buildin contractor) (date) s <br /> a: <br /> ZONING ADMINISTRATOR <br /> „ Q <br /> TOWNSHIP PERMITS MAY BE REQUIRED N 1 o o r m <br /> mn <br /> . <br /> 8888888 $ r <br />