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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <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 w <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 <br /> regulati ?s of the State of(Wisconsin. n <br /> . 'eSo►� Pilo S wlci'G+rf Jo <br /> A a f <br /> OWNER (Pleas Print) (` �( Cont raaororSurve�ororAgett o <br /> Atltlr s�[1 tt�� (� Addr s j / n <br /> fXtG L_ ffr 7I 0 ���iNSL`vw V.i' <br /> City, State, Zip Code ` City,State, Zip Cod <br /> Telephone Telephone r. <br /> Emergency/Fire No. and Road Name / <br /> Legal Description (as Indicated on tax statement) <br /> n L7 — <br /> Permit(s) Applied for: 3 °- <br /> a <br /> Dwelling Addition ' Filling/Grading Camping Unit S °- <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> 1! t <br /> Structure Use: <br /> (family home/cabin, garage, addition, -etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <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 Iocatlon 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 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 and m 11 H <br /> dated by the owner. C T% <br /> PLOT PLAN N t <br /> 81Rr-N' 1S AywJ i~ M s <br /> (le-e SMU-41 <br /> 4\ <br /> (3R9) <br /> o <br /> �,�yz _ <br /> �, � <br /> n"E <br /> ✓i 3° �Y <br /> e rj <br /> D (n tnvu� r DL <br /> 0 <br /> D Q > j � a � m <br /> .. CJA`.} z m m' m�ii,z 1 <br /> 4 - - <br /> cc <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S : m 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- m N' O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 ^� <br /> access to the abov described premises at any reasonable time for the purpose of inspection. m 8 m <br /> n 3 pA ? <br /> M N O <br /> SIGN HERE .0 ^. <br /> (signature-.yf owner or build in rac Id e) o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PER ITS MAY BE REQUIRED m <br /> �P� o N w o ,'o sb' m <br /> 8888888 U) <br />