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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> ;v T <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ro <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. m I <br /> I f w � <br /> '�r/eS V . wc�prntefPY cC� a o <br /> OWNER (PI se Print) Contractor or Surveyor or Agent o m <br /> ��3�� cl. Side br <br /> Address Address <br /> M , r, ,, Fvn Bch M s-s 3 y 3 <br /> Ciry, State,Zip Code 1 City, State,Zip Code <br /> � ►a- 93 �' <br /> 3716 �I�Sb -'1�? 7, <br /> Telephon(es, // / Telephone <br /> -S <br /> �5 S� / /'f7 (�'QGV <br /> Emergency/Fire No. and Road Naine <br /> Legal Description (as Indicated on tax statement) <br /> o 0 <br /> Permit(s) Applied for: o ^- <br /> J <br /> w � <br /> Dwelling AdditionFilling/Grading Camping Unit o <br /> Z o <br /> Accessory Building Sanitary P Subdivision ° <br /> Garage �-�' A` n <br /> Structure Use: �- V 1 iii IICJiV ' C- �I 1 fyVL = r(j <br /> (famil ome/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). o <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 z <br /> measurement to the ordinary high water mark of lake,stream,or river. o o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m ( t I y <br /> dated by the owner. C <br /> I <br /> PLOT PLAN m (n <br /> I C <br /> o <br /> o <br /> N <br /> Z <br /> 1 <br /> I� <br /> ro o c m n g <br /> m. Da� nN awy <br /> w < wcwO Jo03 <br /> ,O <br /> C d G 0 M <br /> F J i T y i Im <br /> Im <br /> g : ac C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o w m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa. www O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor-- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g w 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- . N <br /> plication. I agree to permit county officials charged with administerin county ordinances or other authorized person to havenN o <br /> access to the above described premises at a y reasonable time r the`dyrpose of inspection. w $w <br /> m <br /> ro ywf <br /> SIGN HERE <br /> �7 f .iii ) P <br /> (Anrown building con (date) s <br /> ZONING ADMINISTRATOR ` <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 . moos m <br /> 9 8888rmn <br />