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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator `' do 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3d' 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v y <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 applicable County Ordinances and the laws and 3 <br /> regulatio s of the State J"isconsiin.-RjpH _o <br /> .� 1\1\ nli p <br /> m O <br /> F <br /> OWN (Plte�ase int) , c I Contractor or Surveyor or Agent o <br /> oZo�X .IIAt)A <br /> ` State, <br /> - Address <br /> � 3 <br /> City, tate,Zip 0 de City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: o °- <br /> J <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Su ivision P <br /> Garage <br /> Structure Use: <br /> (family hom !cabin,garaggif, a &tion, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). a <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). aw <br /> 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 o <br /> III Z Qx <br /> measurement to the ordinary high water mark of lake,stream,or river. o o. ` <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andm y. <br /> dated by the owner. <br /> Uj <br /> C , <br /> PLOT PLAN m <br /> 1 ' ; 1 t Z <br /> n_ <br /> o` <br /> J <br /> N <br /> O <br /> J <br /> m <br /> O � y <br /> I <br /> Z <br /> o c 7 y m o a F m <br /> m - ii•� nm aA M <br /> o A< 101cHo05003 <br /> o @ <br /> YJ TN m <br /> gm <br /> N Oo@ O <br /> 8 a c^ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c '^ 1D m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa' a m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- `b' m <br /> mation 1 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 agree to permit county officials charged with administering county Ordinances or other authorized person to have u, <br /> access to the above described premises at an reasonable time for the purpose of inspection. m g o <br /> m ` :I 3 <br /> R A <br /> SIGN HERE <br /> (signature of 5wner or building contr <br /> o . <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS AY BE REQUIRED APR 3 O 19TV e o m <br /> 888rmn <br />