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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ro m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and '3_ <br /> regulatiorp of the State of Wisconsin. m <br /> N m <br /> OWN R (Please Prim) Contractor or Surveyor or Agft „ <br /> 9 2 2 San u S- <br /> d <br /> Addre s W Address <br /> City, State,Zip Code City,State,Zip Code r E <br /> 0( <br /> Telephone Telephone <br /> Emergency/Fire No. and Roe?N me <br /> Legal Description (as Indicated on tax statement) o <br /> n O <br /> Permit(s) Applied for: o ° <br /> Dwelling Addition Filling/Grading Camping Unit 0 0 <br /> Z v <br /> 'o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage } <br /> Structure Use: <br /> (family home/cabin, garage,addition, -etc.) a <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). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). (1 3 '� <br /> 3. Show dimensions infest of thefollowing:(a) bulldingto all lot lines,(b)bulldingto center line of road,(c)building on 0 ^- v <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. M separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m y' <br /> dated by the owner. t <br /> C <br /> PLOT PLAN a tCz <br /> fA � •" <br /> I <br /> O <br /> _ c <br /> S o <br /> + m <br /> I90 <br /> J CL a �O <br /> �jon Clace. ) N <br /> ,. I.c <br /> 0 <br /> 7' <br /> Z <br /> I� <br /> o c m m n n m <br /> M <br /> m_. D�� aaN aro <br /> noM0m3 <br /> o >: Z= m <br /> N <br /> �^ rn ! Off : ' O <br /> \y 8 € m M <br /> I 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 O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. $ 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- a <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> O o : <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ <br /> m 3 <br /> ro A u <br /> ro <br /> SIGN HERE <br /> (sig ur of owner or Vijoinomtractor) (date) <br /> o , x: <br /> ZONING ADMINISTRATOR ; $ <br /> TOWNSHIP PERMITS MAY BE REQUIRED N 00 m <br /> 8888 $ 888umi <br />