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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -00 0 <br /> 2. <br /> APPLICATION FOR — LAND USE — PERMITS d3 <br /> 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 ro <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. <br /> w � <br /> n O <br /> F <br /> OWNER (Please Print) C ntraaor or S rveyor or Agent _ o <br /> �� �yG/AJh CcyS% <br /> Addres§ Address 1 <br /> 3e%537 h'/`/liC/z �/�• .�t� . <br /> City, State,Zip Code _C==L <br /> Zip Code <br /> Telep one ` Telephone <br /> Emergency/Fire No. and Road Name 1 <br /> Legal Description (as indicated on tax statement) <br /> n C) lL„J1i 1 <br /> Permit(s) Applied for: o o <br /> J <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit o °— <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) g <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top vieyf)... , <br /> 1. Show the tng buildings (EB) and (NB) and Indicate North (N). M o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfleld (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 1111 Z <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 y <br /> dated by the owner. m 0 <br /> C <br /> PLOT PLAN06X 111111M <br /> o � <br /> � ro <br /> o <br /> -10-V cI11AP1T/c/U <br /> am <br /> �i <br /> V <br /> u� <br /> _ <<_ ` N S 3 <br /> N . <br /> T M <br /> m <br /> m C <br /> 8 " I <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.1 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- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 /> 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 prey i at any reasonable time for the purpose of inspection. w 8 <br /> m 3 ^V <br /> A <br /> SIGN HERE �^w <br /> - (signature of owner d' ejD <br /> ZONING ADMINISTRATOR Q <br /> TOWNSH P PERMITS MAY BE REQUIRED <br /> APR 28 � iK 8888m <br /> �I ,, � 8888888rmn <br />