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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) m a o <br /> _. E <br /> APPLICATION FOR — LAND USE — PERMITS 3, o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and ie L^� <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 <br /> regulations of the State of Wisconsin. o JyJ <br /> c m <br /> �� 5ov` �- ►3 .1d�s a �� <br /> OWNER (Please Print) Contractor or Surveyor or A ent o <br /> ZO 3 ' � <br /> m <br /> Address Address (1 � <br /> C— -.- = 75-y xN v Sy Too I T� <br /> City, State,Zip Coe City, State,Zip Code <br /> 479 ^ <br /> Telephone 21 <br /> P Telephone <br /> tv C�1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permlt(s)Applied for: o <br /> o <_. <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit o 0 <br /> Z <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° o° <br /> Garage 1� 'I <br /> Structure Use: i taws_ <br /> r <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <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 draiMield (OF). <br /> 09 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 11 ' 0 <br /> measurement to the ordinary high water mark of lake,stream,or river. an o S <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and y <br /> dated by the owner. o <br /> C i <br /> PLOT PLAN (A ? <br /> i <br /> i <br /> O I <br /> I I y <br /> s <br /> _ <br /> CIQ <br /> O ti <br /> N <br /> VVVP <br /> D W0) rprDDp � <br /> D o c <. m m o a m <br /> �. D6� aK a2 <br /> 9 m0< m C N O J <br /> Z ry ? m Q ? 1 <br /> m <br /> L" [ C O <br /> g maS C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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 informs- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. $ m <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g 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 u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 8 . <br /> m m A m <br /> HERE 9_ Z3 _ (3•� w (w`� <br /> sina6re f owner or irg contractor) (date) ; <br /> 'TR TOR <br /> TOWNSHIP PERM TS MAY BE REQUIRED g o $ <br /> 8888888 <br /> J <br />