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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q w ° <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 3 n <br /> regulations of the State of Wi tonin. <br /> jLbo — <br /> nOid 7� 1�od D <br /> OWNER (Please Print) T l l �� n f <br /> Contractor or Surveyor or Ag o <br /> 1 C�1� E-r't P t <br /> d _ <br /> Address. - Addres l-- '5y <br /> � 1 <br /> 1 �YIO,r U/ I y o <br /> City, State,Zip ode City, State,Zip Cod ' <br /> Telephone <br /> Telephone ,�J <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s)Applied for: 0 0 <br /> o < <br /> Dwelling AdtlitionFilling/Grading Camping Unit o <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage } <br /> Structure Use: <br /> (fatuity home/cabin, garage, addition, etc.) <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 grainfield (DF). 0 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 3 <br /> measurement to the ordinary high water mark of lake,stream, or river. Z 50Q <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner, m o <br /> C CIO J <br /> PLOT PLAN a <br /> Ata <br /> m <br /> AtaGhPat_ SSS L <br /> ( <br /> ! f <br /> l I � <br /> � o <br /> t0 <br /> o <br /> v 1 <br /> 0 <br /> m <br /> o � <br /> y�ce � k" �Pw lofi u ��f <br /> U <br /> re''f aarecX , /J <br /> j1-511 fo ,('!�/L,e S <br /> uF <br /> 0 o c T m m o a t/ mMm <br /> p J n p <br /> m. Dai . aN }, rt as�J <br /> N.0 C <br /> C < < .� O J fO <br /> 2 ' o 0 <br /> m ,z 1 <br /> P a <br /> f = m:ZA m <br /> 33 <br /> j mei c <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my know l- ��� 8 8 m m G <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- H C)H O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor v <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 _�, <br /> 8 . 8 : <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 ^r <br /> access to the above described premises at any reasonable time for the purpose of inspection. 00 o <br /> T 3 8 n <br /> m v ^ m <br /> SIGN HERE <br /> N N <br /> (signature of owner or building contractor) (date) � .+ <br /> ZONING ADMINISTRATORAG�;7LA I 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> rn+n am .I}'ioo i� m <br /> 88888 $88x, <br />