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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 00 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> m b <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 '3 <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulat' ns of the State of Wisconsin. H m <br /> f <br /> 0 N R(Please Print) Contractor or Surveyor or Agent o L <br /> Add e s Address <br /> m <br /> �vl�Sa.-. <br /> City,State,Zip Code City,State, Zip Code ti <br /> / t S 3 g.6 AZI <br /> TelTne3�� 7 r r N Telephone I T <br /> Emergency/Fire No. and Road cName <br /> V) <br /> Legal Description (as Indicated on tax statement) <br /> � L) <br /> Permit(s)Applied for: 0 o <br /> N r- <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Building SanitaryP "vy Subdivision ° } <br /> Garage <br /> Structure Use: <br /> `r CiCt /i, V 1 r <br /> (family home/cabin, garage, addition,etc.) � 0 <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 grainfield (DF). <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. a n rn <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m N V�', <br /> dated by the owner. C I o r11 <br /> , ' <br /> PLOT PLAN m C S <br /> -:5e chPo�- Pim- PLPAJ t IR <br /> 0 <br /> N Its, <br /> O V <br /> Q <br /> m _ <br /> O y <br /> n <br /> Z <br /> 4-4 <br /> I <br /> wN <br /> o � tnr DDp <br /> m c . m m o n <br /> Iv <br /> o E 0 T� i <br /> m <br /> g = Wim : i a <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.I acknowledge that I am responsible for the detail and accuracy of all informs- w m H O <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. 1 $m g <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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> Ou, <br /> . o <br /> access to the abo described pr mises at any reasonable time for the purpose of inspection. . m $m <br /> ro ^ e <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) o x <br /> ZONING ADMINISTRATOR J g <br /> TOWNSHIP PERMITS MAY BE REOUIRED N o,'o�$ m <br /> $ 889889rmn <br />