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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> m d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <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 UseOrdi ce,Sanitation Code,and with all other applicable County Ordinances and the laws and _. n <br /> regulations of the State of s nsin. w m <br /> ��/.��5 c <br /> f <br /> OW- W(Please Print) Contractor or Surveyor or Agent m O R <br /> X30/ <br /> Addr 1�w` � GR Address ^ <br /> r 'U / ( 1 <br /> C ty, State,Zip G de s/ City, State,Zip Code t <br /> Tel c / Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o <br /> Permit(s) Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit ° V, <br /> M <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage <br /> Structure Use: iU� <br /> (family homelcabin, garage, additon,etc.) r <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) A <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 IIIZ `c <br /> measurement to the ordinary high water mark of lake,stream,or river. C n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and o <br /> dated by the owner. C <br /> PLOT PLANM Z <br /> M <br /> 0 <br /> o <br /> N <br /> r <br /> Z <br /> o c m m n n g m <br /> y mm M <br /> g m < 6 ; <br /> Z o 0 o 1 <br /> P c y m <br /> to u c C <br /> 8 a , : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- e `� In <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs. c ` yy!!m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- ZS n N <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 [ O i7 0 <br /> access to the above scri premises at any re able time for the purpose of inspection. o <br /> n E 3 s <br /> e <br /> SIGN HERE <br /> (sig—naattuyre of owner or building tractor) (date) c s, <br /> ZONING ADMINISTRATOR /Int I '�laCi . $ . . . . <br /> e N, <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8 o o <br /> 8988888u <br />