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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U m -I o <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 m <br /> ° UN <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 J <br /> regrIo s of the State of Wisconsin. <br /> l/5'Q L� lI s=ic � fa <br /> Olease Print) / Contractor or Surveyor or Agent <br /> c £, <br /> M& orc � ard qv /U <br /> dress Address <br /> 0.1 f` U D /1 �V Al g"Q. r/� rYLt i'✓ <br /> City,State,Zip Cbde S S y� City, State,Zip Code <br /> Telephone Telephone t <br /> Emergency/Fire No. and Road Name C <br /> Legal Description (as Indicated on tax statement) o <br /> 0 <br /> Permit(s)Applied for: o ° <br /> J <br /> Dwelling Add'Ri Filling/Grading Camping Unit o <br /> z o <br /> Z <br /> Accessory Building Sanitary Privy Subdivision $ <br /> Garage a <br /> U1 <br /> Structure Use: 00 <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <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 <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 Z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. qjC <br /> PLOT PLAN Ole <br /> W— M <br /> _-. <br /> M <br /> rn <br /> p g <br /> X o' <br /> J <br /> I , <br /> _ o <br /> J <br /> J <br /> m <br /> o � <br /> y <br /> i <br /> I <br /> I n o c m m a g m <br /> 1\ m. mM K 4 I H g1 = a <br /> t <br /> o m p <br /> O F J <br /> T <br /> .0 s . € m <br /> I declare that this application(Including any accompanying s hedule)has been examined by me and to the best of my knowl- m <br /> � � m� <br /> edge and belief it is true,correct and complete.I acknowledg that I am responsible for the detail and accuracy of all informs- fy!� m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 1$ 'o i7 <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I I 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. a a ` w g m <br /> B $ ^ " <br /> SIGN HERE ` N n [ <br /> (signature of owner or bull <br /> h'ng ccontrac (date) o s <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o S m <br /> � 999MW <br />