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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 /> m <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 m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the Stateof Isconsin. m (" <br /> O ER le Print Contractor ury ororAgent 1 <br /> 12, U�i E! 11� �J I ra, V <br /> tlress Address <br /> �q 1 -- <br /> �t5 vr�Z N S V l ,l �, � (� AJ �.�:�� <br /> City, State,Zip Code City,State, Zip Code <br /> �. <br /> Telephone Telephone <br /> S� 76 or p as <br /> E ency�F' tNo. andRoad'Name <br /> /v <br /> No at -23(3 ' ) .t/ <br /> Legal Description (as Indicated on tax statement) o �/1 <br /> 0 <br /> Permit(s)Applied for: o g <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit o °— <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o 9 <br /> Garage <br /> Structure Use: A) .25 ' X,15 r <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <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 0 0 <br /> (W),septic tank (ST), and drainfield (D�. 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 0 z c <br /> measurement to the ordinary high water mark of lake,stream, or river. o 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and n H <br /> dated by the owner. C �( <br /> PLOT PLAN 48 yiJ <br /> Lv S C <br /> AIce <br /> PRr vy II �t 5 3� <br /> 0 o I _ <br /> G Icy` <br /> Gv, <br /> o � <br /> bj © eD j W <br /> 7 <br /> �32�CsT 'to f <br /> ro <br /> k/o •Aye .= � m _ ' a � am M <br /> PCZ ��S�CIf5� h Z ? o 3 <br /> N . m <br /> Cg mom : c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o `� 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 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 g rt 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 O 00 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 8 0 <br /> 0 : <br /> ro A m <br /> ro <br /> SIGN HERE <br /> n : <br /> (sign r of owner or D 'ding contracto (date) <br /> ZONING ADMINISTR R 8 <br /> TOWNSHIP PERMITS MAY BE REQUIREDm <br /> 88888888 <br />