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Z ('co) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o c <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 2. <br /> 9 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 0 <br /> regulations of the State of Wisconsin. w m <br /> m <br /> OWNER jPlease Print) I Contractor or Surveyor or Agent m m <br /> V-6, `1v4 C,o. Ind <br /> Address _ Address <br /> 1M-e- b L r VV 1, S l <��� -_ <br /> City, State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> 0 <br /> Permit(s) Applied for: <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit ° g <br /> Z c J <br /> Accessory Building Sanitary Privy Subdivision ° a <br /> Garage 1 <br /> Structure Use: <br /> --(family home/cabin,garage, addition, c.) g <br /> 1A <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). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (DF). 3 w <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)buildingInZ `o <br /> measurement to the ordinary high water mark of lake,stream,or river. G <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 9) o <br /> dated by the owner. C 'I J <br /> PLOT PLAN <br /> I <br /> J <br /> o <br /> w <br /> r <br /> 2 <br /> i; <br /> D <br /> on C � U" wr tai Q E n <br /> zo <br /> A < : Z w o 03 033 <br /> @ w O2 <br /> P Y J r ' 7 <br /> �: <br /> n <br /> 2 : <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> ` 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- y!m C <br /> lion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor. <br /> mation I em providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 18 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 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. ro $ ,� <br /> m : <br /> � nb : <br /> SIGN HERE (�.r,t X:.`v__ .�' Ti ' <br /> (signature of owneruildin c tractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PE ITS MAY BE REQUIRED ffi o o 8 r <br /> ;888888881 <br />