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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn 0 0 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 and71 c U <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulationsofthe St a of Wisconsin. H m <br /> lCll <br /> OWNER (Please Print) Contractor or Surveyor or Agent o S m <br /> � s9 �— w, T3Oss LX 2d <br /> Y �4 Address <br /> City, State, Zip Code r �t/ City, State,Zip CodeWei ^ , <br /> Telephone G (i� Telephone <br /> pG <br /> �- � 4�1� <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> � G) <br /> Permit(s) Applied for: 0 o ,� <br /> y <br /> Dwelling Addi illing/Grading Camping Unit <br /> Z S <br /> T <br /> o <br /> Accessory Building Sanitary ivy Subdivision ( , <br /> Garage � � �•1 <br /> Structure Use: - <br /> (family home/cabin, garage,addition, etc.) �r 1 <br /> 11 IflLtl��fJ'1J' <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 (W),septic tank (ST), and drainfield (DF). 2 3 v <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 Q <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 H (� <br /> dated by the owner. C fig <br /> PLOT PLAN m `?`° r- `� 1 <br /> ` I <br /> I� <br /> W <br /> O � y <br /> V' <br /> 'iw;)Z <br /> 30 <br /> ( <br /> A o C <br /> M <br /> o £ o <br /> T'20 M <br /> 0 -. N m <br /> H c <br /> 8 . mM <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.1 acknowledge that I am responsible for the detail and accuracy of all informa- a 0 H G <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 n <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I V g w $ <br /> further accept I liability which may be a result of the County of Burnell relying on this information I am providing in this ap- y, <br /> plication.I ogre to permit county officials charged with administering county ordinances or other authorized person to have N <br /> O O : <br /> access to the ove described p mis at any reasonable time for the urpose of inspection. q 3 $ g <br /> Aa <br /> SIGN HERE <br /> (signature of owner or bu' in o r o date)p/ . o <br /> ZONING ADMINISTRATOR ~/�_ 72� Lg <br /> TOWNSHIP ERMITS MAY BE REQUIRED 10 3 . <br /> 8, 8 8 8 m <br /> 88 888ai <br />