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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ( --0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> ;v 0 <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described a m 5 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of t <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws an J 3 a <br /> regu ations of the State of Wisconsi <br /> A Ades <br /> `o m o <br /> n p £ <br /> ON Please Print) Contractor or Surveyor or Agent o <br /> Add s Address <br /> iv <br /> City,State, Zip CodeCity,State,Zip Code <br /> ioe <br /> Telephone Telephone <br /> 7��- Telephone �) <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> CD <br /> ci <br /> Permit(s) Applied for: 0 'C- _ <br /> Dwelling Addition v Filling/Grading Camping Unit o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: - <br /> 0 <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 00 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). a3 <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)buildl ig 1A ` <br /> Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed ai id m <br /> dated by the owner. C 1 1 <br /> PLOT PLAN � <br /> Ads <br /> PuT <br /> �l 1 <br /> m <br /> Q <br /> o <br /> N <br /> C) <br /> Z <br /> C <br /> o c M. m m a m <br /> �. Dara a M <br /> � '< : 12 H jam' 3 <br /> z s : =i <br /> a £ M <br /> cn '. O <br /> m C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my kn wl- 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 infor a- Fn N p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation <br /> or-mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 8 <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- N <br /> plication. I agree to per cou officials charged with administering county ordinances or other authorized person to ave <br /> access to the above d premises at any reasonabl tim r e purpose of inspection. m 8 0 <br /> r 3 <br /> co <br /> a <br /> SIGN HERE 404 <br /> (sign r' a <br /> (sia of o ne or building cc tractor) (date) o x <br /> ZONING ADMINISTRATOR g <br /> H <br /> ~ <br /> TOWNSHIP PERMITS MAY BE REQUIRED PNN <br /> n n o o .`b' m <br /> 8 $ 888888r'"n <br />