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Burnett County 7410,Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,U) - 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 <br /> ii <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 a 1 <br /> regulations of the State of Wiscons'n. H m_ <br /> -Pt' ', ffina <br /> ro <br /> OWNER (Ple se Print) A Contractor or Surveyor or Agent o <br /> L-I m <br /> Address, l0 <br /> - Address <br /> .� <br /> City,State,Zip Code ' ; City, State,Zip Code ti <br /> Telephone Telephone <br /> I <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> 0 <br /> Permit(s)Applied for: o �- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit g o _ <br /> v <br /> Z ° J <br /> Accessory Building Sanitary Privy Subdivision ° � <br /> Garage <br /> Structure Use: v <br /> (family home/cabin,garage, addition,etc.) Imo <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). c <br /> 2. Show the location of the well (W),septic tank (ST), 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 Z c <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 <br /> dated by the owner. C) <br /> C <br /> PLOT PLAN /C m j1J Z <br /> ON <br /> 0 <br /> m <br /> o <br /> Z <br /> �c <br /> o c ro d n FS. m <br /> "< � : ,Ze0ZM 3 <br /> o f a Q . -1 <br /> uM <br /> G) m[ E � ! C <br /> 8 : mm a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- w m H <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 $ <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_ 'j n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 8 m <br /> m i 3 n . <br /> A m <br /> SIGN HERE a <br /> (signature of owner or u' ing contr c a1 o s <br /> ZONING ADMINISTRATOR O $ <br /> TOWN P PERMITS MAY BE REQUIRED $ , o 8 8 m <br /> 8 <br /> 8 $ $ v, <br />