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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m a o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. 0 <br /> m a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m u <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the tate of Wisconsin. w m <br /> ��Ef1svN SELF a £ <br /> OWNER( ease Print) Contractor or Surveyor or Agent c <br /> S 2 i No B/+ s l9 f�K= Rd <br /> Address Address <br /> [,)A Ails 041124 <br /> City, State,Zips City,State,Zip Code lam) <br /> 7 <br /> Telephone Telephone I <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n O <br /> Permit(s)Applied for: 0- <br /> m r � <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage <br /> �B <br /> �j� Oew)tL <br /> Structure Use: ( � ' d lko <br /> (family me/cabin, garage, ddition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 3 N <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building Z <br /> measurement to the ordinary high water mark of lake,stream,or river. G <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. C <br /> PLOT PLAN M <br /> LSI � <br /> 8 N <br /> m <br /> � Iv <br /> o <br /> Z <br /> i <br /> o c m m n n F m <br /> R. <br /> Z o Z.2 ' -1 <br /> 0 <br /> o S � i € m <br /> c <br /> I declarethat 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 informa- i y!m 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. I 8 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have- <br /> access <br /> ave access to the above de cubed premises at any reasonable time for the purpose of inspection. m $$ <br /> � Au : <br /> 1[/�O <br /> SIGN HERE <br /> (signature of owner or building goniray� L.. (d 7a <br /> o ;V: <br /> ZONING ADMINISTRATOR /f/y�s��,d'/J� ' if <br /> TOWNSHIP PERMITS MAY BE REQUIRED $ 00 LS m <br /> � 8 $ $$ 8UM) <br />