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Burnett County 7410 Co. pd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. — <br /> O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Cl ' <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. n m° <br /> N �^ <br /> Je-"v <br /> f <br /> OWNER (Ple <br /> 8aas Print) Contractor or SurveyororAgent o <br /> a 8 <br /> Addr ss Address ` <br /> �yexFal)s <br /> City '�,Zip Code City,State,Zip Code <br /> 1J146gga k4 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) ° <br /> � O <br /> Permit(s) Applied for: a <br /> r <br /> Dwelling —X— Addition Filling/Grading Camping Unit ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: / 5 <br /> (family home/cabin, garage, addition, etc.) <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). 9 o v , <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 03 u <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 Q <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 m H <br /> dated by the owner.n / <br /> pC t <br /> PLOT PLAN �_ /ry_ wYf— 's&-�G1`� <br /> ( a7� vvV III"" /// �9 m <br /> ! ? 3 <br /> N <br /> 0 <br /> O � <br /> o ( <br /> 75 aNnv nraDpV <br /> D <br /> O 0303 <br /> N <br /> f�T m <br /> ®que G <br /> s <br /> 8 : € M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know) 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 informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 800 0 <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 $ <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 u t7 <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m $ <br /> m 3 n r : <br /> SIGN HERE <br /> (signature of owner or building contractor) e c ? <br /> 8 <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MA E REOUIRED <br />