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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. _ - <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � \ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the „ SJ <br /> Burnett County Land Use Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. H m <br /> m <br /> - F12Moor Lp ,rtt' Co ,,sin_uc7` ,oO <br /> OWNERPrint Please <br /> ( Contractor or Surveyor or Agent <br /> T ) o <br /> AddressU S <br /> _Z Z4 lei(fbm L.d lc M_ JJ,�r Vie 12- 775- /.�, 2.e, A 'p <br /> Address U' <br /> G 2H .,-rs o <br /> City, State,Zip Code City, State,Zip Code <br /> 7 ,5 — <br /> Telephone Telephonef <br /> :5-'!5 Lq ,rc <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s) Applied for: o <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Accessory Building Sanitary PrivySubdivision <br /> o <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <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 ,se ° <br /> (W) tictankS <br /> (p T), 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 o <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 C N" <br /> dated by the owner. m o <br /> C <br /> PLOT PLAN to , <br /> M <br /> w <br /> 8 <br /> 0 <br /> 0 <br /> _o <br /> N <br /> o c mm n a y -Mu <br /> a Do.� mam am M <br /> < -2 e O <br /> f = to m <br /> Ns moi O <br /> g <br /> m ` i y <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I A <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 v, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> ro v <br /> SIGN HERE ."�.�.�."�` 42 — l ` _ <br /> (si a of owner uildin/gcontractor) (date) Y vo R, <br /> ZONING ADMINISTRATOR "1 '�7J�" <br /> H +NNNN <br /> TOWNSHIP PERMITS MAY BE REQUIRED mT <br /> $ $ $ 88888ar <br />