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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o o c <br /> � f <br /> APPLICATION FOR — LAND USE — PERMITS m o <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 <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and - <br /> regulations of tIp State of Wisconsin. ) w m <br /> h0 d)Q /� .�c�nuigr� 2n..rr /-ed S6cf a C� <br /> TN <br /> NIB Print Contractor or Surveyor or Agent m <br /> m <br /> Aer/es1 q ,^ �/ Address <br /> City,((F�StatedZip Code City,State,Zip Code <br /> Telephone Telephone <br /> I <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> � O <br /> Permit(s) Applied for: °. <br /> m � <br /> Dwelling Addffi ' 'ng/Grading Camping Unit o °^ <br /> v t <br /> Z o <br /> Accessory Building Sankary Pri Subdivision ° A <br /> Garage __ <br /> Structure Use: 0C <br /> (familyhome/cabin,garage,addition, etc.) A <br /> I g1�' <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 00 ' <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 dralnfleld (DF). in 3 <br /> 3. Show dimensions In feet ofthe following:(a)building to all lot lines,(b)building to center line of road,(c)building in <br /> Z 3 <br /> measurement to the ordinary high water mark of lake,stream,or river. No o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 0 <br /> dated by the owner. C ; ) <br /> PLOT PLAN <br /> l�J �a � � v� �► <br /> w , Cn <br /> 0 <br /> m � <br /> o <br /> N <br /> L4 S` , Yx we t( 1 <br /> I / <br /> to 4441. z <br /> W � <br /> I <br /> f <br /> n oc z� mm �n � m <br /> MIR � = � <br /> g m o [ <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- o � , 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 informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 75 ao <br /> motion 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g m 8 <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 /> pllcation.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. T 3 8 <br /> A a <br /> SIGN HERE J' a <br /> (signature of owner or building contra)or) (date) o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED I DI <br /> o 025 m <br /> �888 $ rma <br />