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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) - a o <br /> APPLICATION FOR — LAND USE — PERMITS - <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <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 3 a <br /> regulations of the State of Wisconsin. �, m <br /> 7f'rr4 w lson 5��� a E <br /> 0 E (I ase Pri t) hcy Contractor or Surveyor or Agent <br /> (SUS <br /> Address i Addres <br /> WeSS) er� t."VT <br /> CV, State, Zip Code City,State,Zip Code <br /> (�lS2 $6G ' 2Y81 ) <br /> l <br /> ` <br /> (T"Telephone Telephone <br /> Emergency/Fire WRoad M5heV Read <br /> Legal Description (as Indicatedon tax�state t ent) <br /> 0 O <br /> Permit(s)Applied for: a o <br /> H ,n <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> Z va <br /> Accesso Buildin Sanitary Privy Subdivision o <br /> ara <br /> a_ <br /> Structure Use: G�r r <br /> (family home/cabin, garage,addition,etc.) I o <br /> 1A <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). o <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (DF). c n <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 andH <br /> M IIVICCJ� <br /> dated by the owner. M Z` <br /> PLOT PLApI <br /> W <br /> T � <br /> i L ) <br /> c� Pil � I00' Uu <br /> c <br /> N o <br /> 3 g <br /> 6- ay � std <br /> F o p v5 P`°tr 0 I� <br /> o vF3 BFS� ER o <br /> p F ; <br /> Y I <br /> (O <br /> — - - ul hey - Roa� <br /> o c m m n V 9 <br /> 0 <br /> O J (O 3 <br /> Oa : : N Z : <br /> £ J M N M <br /> c ^ m <br /> c� C o <br /> g : ma M <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S 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- <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 m <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- i <br /> N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have ,„ <br /> access to the above described premises at any reasonable time for the purpose of inspection. m <br /> SIGN HERE <br /> ignaturwner or building contractor) (date) <br /> ZONING ADMINISTRATOR Im I�nL I� E g <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIRED $�a m �d o 0 8 rrm <br /> 888888 (r, <br />