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2 i � _ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872- Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c <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 [� <br /> regulations of the State of Wisconsin. w m <br /> c <br /> 1 t "-f 5e -- O <br /> OWNER (Please Print) ` / r Contractor or Surveyor or Agent o <br /> Address ' Address <br /> City, State,Zi Code City, State,Zip Code JA <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) S' �? ( {<Q f�7 Z�C- o <br /> Grow, 1 <br /> Permit(s)Applied for. �'G I 0 ;- <br /> Dwelling Addition Filling/Grading Camping Unit S °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o 1 <br /> Garage p�(? <br /> Structure Use: /' '"' i��� Aid, <br /> (family 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 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). a m <br /> 3. Show dimensions infeet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building z `a <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 and m y <br /> dated by the owner. <br /> PLOT PLAN (A <br /> p <br /> � ..� pry , <br /> 1 � <br /> r, I <br /> o <br /> � t <br /> Z <br /> mp � fell <br /> C OL, �� v ---------- <br /> 0 wm <br /> A. Dai a nm a M <br /> 3 <br /> z � Vi ? "o °z 1 <br /> f ! i 71 it M <br /> � <br /> c m 2j : o <br /> 8 i M <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- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. L $ $ a <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 m0 . <br /> access to the above described premises at any reasonable time for the purpose of inspection. 8 <br /> m 3 <br /> A a .: <br /> rye oa <br /> SIGN HERE « <br /> (signature of owner or in cot (d e) o x <br /> ZONING AD NISTRATOR 8 <br /> TOWNS P PERMITS MAY BE REQUIRED S"n rn N o o m <br /> 8$ $ $ $ $ $ $ ai <br />