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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,N, ' o c <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> iu o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> w <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 3 <br /> 'v <br /> regulations of the State of Wisconsim , <br /> 01% <br /> OWNER(Please Print) Contractor or Surveyor or Agent o m <br /> Address Address I Ufa .�.�. <br /> City, StCity,State,Zip Code <br /> ate, Zip Code <br /> Telephone Telephone j <br /> J , <br /> Emergency/Fire No. and Road Na e r <br /> 11"1lnPf ✓ l <br /> Legal Description (as Indicated on tax statement) <br /> Z L7 <br /> 0 <br /> Permit(s) Applied for: o <br /> Addition ° g <br /> Dwelling � Filling/Grading Camping Unit � <br /> z o <br /> Accessory Building Sanitary Privy Subdivision i <br /> Garage <br /> Structure Use: I i� 6 kUoY-n ED-' K sJ o <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <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 (Vi),septic tank (ST),and drainfield (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 � Z c -F <br /> measurement to the ordinary high water mark of lake,stream,or river. <br /> 0 <br /> 45. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. C xJ <br /> PLOT PLAN 5 clvrSr <br /> �S.'t <br /> Cn <br /> r, <br /> 1 n <br /> / 1 <br /> 0 <br /> PC � <br /> 0 <br /> > > v <br /> e J <br /> 7113 <br /> I � <br /> I� <br /> U)to T o m o Do. 9 <br /> � m0 � . 3 <br /> v <br /> 2 m <br /> P <br /> m ,z 1 <br /> o <br /> ut " E m c C <br /> g m m D <br /> 1 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 accuracy detail responsible for the detaand acuy of all informa- <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 . <br /> Aw . <br /> SIGN HERE <br /> (signature of owner orbuilding contractor) (date) <br /> $ <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 88888888m <br />