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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d o9 � <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � w N' <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the '^ o <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 Wiscgt>,sin. V <br /> m <br /> n O <br /> OWNE Please Print)) Comractor or Surveyor or Agent o <br /> .SPR INFVl cv iJA <br /> Address �� Address t <br /> L�/ C u D./3 v <br /> City, State,Zip d City, State,Zip Code <br /> 73F 5, 7� s 0 <br /> Telephone Telephone <br /> Emergency/Fire No. d oad ame <br /> Legal Description (as Indicated on tax statement) o G <br /> n a <br /> Permit(s)Applied for: <br /> m <br /> (�1 <br /> DwellingAddition Filling/Grading Camping Unit77X— <br /> o _- <br /> v J <br /> z <br /> Accessory Building Sanitary Privy Subdivision P o <br /> m <br /> Garage _ <br /> Structure Use: 'E'r(_ r h S�iYrc� 61,fCAl <br /> (family home/cabin, gafage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M <br /> 2. Show the location of the well ,septic tank S o <br /> (W) p ( T), and drainfield (DF). 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 <br /> � Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. ono o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and n H <br /> dated by the owner. M <br /> C I <br /> PLOT PLANin <br /> /V Q <br /> 0 IJ <br /> O <br /> b <br /> I� <br /> r� C % _ <br /> C S( A) <br /> 52 <br /> A on m <br /> A. Dai '-. a a M <br /> c "< '2 « o3 <br /> 00 M <br /> �1 bti" r K `�/ of i� 2 o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o a m 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- N a N 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. 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. . m g m <br /> ro V A <br /> SIGN HERE <br /> signatur f owner or iLop ntra (date) z, <br /> o : <br /> ZONING ADMINISTRATOR <br /> N <br /> TOWNSI PERMITS MAY BE REQUIRED TN o o N$ m <br /> $ 8888888 (Mn <br />