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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator --4 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v H <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 a <br /> regulations of the State of Wisconsin. y a <br /> 11� r Icy W'.0,S a Q 0 <br /> OWNER (Plea a Print) rt <br /> Contractor or Surveyor or Agent o m <br /> m <br /> a <br /> Address Address <br /> 11 Sag 1Jor`Fk S[<o�e `jjr. <br /> r State, ip Code City,State, Zip Code ( 70 f�, <br /> Telephone Rol _ �$3 Telephone ) ,Q <br /> Emer envy/Fire No. and Road Name <br /> � ISSq IlioY+t . S�ot� <br /> Legal Description (as Indicated on tax statement) <br /> � 0 <br /> Permit(s) Applied for: o cQ <br /> < s <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> 3 <br /> Z 0 <br /> Accessory Building Sanitary �,—�_ Subdivision ° � <br /> Garage 1 �_- <br /> Structure Use: <br /> anvil hom cabin, rage,addition, etc.) Uj <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) Q r <br /> r <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfleid (DF). 3 'd <br /> 3. Show dimensions Infest of thefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building Z c <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 <br /> dated by the owner. A <br /> I <br /> N <br /> PLOT PLANm + <br /> n G <br /> P l tr Pic-)-n o T <br /> s _qj <br /> � C T <br /> o yfi <br /> N <br /> 79 <br /> ^ 0 <br /> Z <br /> I <br /> m o c m m o n g L <br /> $ - ii� }.a0 a $ a <br /> o m < . m o 3 m 3 <br /> Z o m Z 1 <br /> ° s i _ 0 m <br /> 1�18i a2 : C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- Cn S i 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 informa- 10 -' yy!! m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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 S <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 Orn 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> m A w . <br /> m m <br /> r w <br /> SIGN HERE �' a <br /> (signature of owner or building contractor) (date) o s <br /> ZONING ADMINISTRATOR <br /> N <br /> TOWNSHIP PERMITS MAY BE REQUIRED rn r?n N o o~d m <br /> 88888888rn <br />