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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> T <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <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. w m <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> m <br /> Address t �r ` Address <br /> 41 <br /> City, State, Zip Code y <br /> P112 � <br /> _7.- City,State,Zip Code <br /> 1s�` �� / / LL r <br /> Telephone 3-)kO�y Telephone <br /> Emergency/Fire No. and Road Name (� <br /> Legal Description (as indicated on tax statement) J <br /> n G) <br /> Permit(s)Applied for: o °. <br /> o — <br /> m r <br /> Dwelling Addb a-- ' 'ng/Grading Camping Unit E °^ <br /> v ()1 <br /> Z o $� <br /> Accessory Building Sanitary Pri Subdivision ° <br /> Garage — <br /> Structure Use: (j) o <br /> (family home/cabin, garage, addition, etc.) (}a <br /> 11 IIJ-V.11 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <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 drainfield (DF). 3 <br /> 3. Show dimensions in feet ofthefollowing:(a)buildingto all lot lines,(b)buildingta center line of road,(c)building z v <br /> measurement to the ordinary high water mark of lake,stream,or river. n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m n <br /> dated by the owner. <br /> C <br /> PLOT PLAN m S <br /> L I� <br /> :T7, Q �C <br /> m <br /> 0 <br /> N <br /> O y <br /> m <br /> Z <br /> is <br /> o E a m m n a F m <br /> mama' '° M <br /> o0� _ N ! m <br /> N : G`) C O <br /> 'm c C <br /> 8 € �;: M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> 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 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 g m g <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 N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 0 <br /> m 3 0 <br /> SIGN HERE <br /> ,r (signature or or uilding contractor) I I (d lel o �, <br /> ZONING ADMINISTRATOR <br /> JUN 1I IIS g '. <br /> (T 3 O '992 N NN N N- (NJ� T <br /> TOWNSHIP PERMITS MAY BE REQUIRED I ` : 00 000 . m <br /> �� ' _ 888 8888y <br />