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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v m <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 /> regulations of the State of Wisconsin. y <br /> w <br /> OWNER(Please Print) '/0't Contractor or Surveyor or Agent o 0 <br /> 36 �j 56I0j <br /> 6 Sj <br /> Add ss Address <br /> �hZL' SCari5 '(02 ( <br /> Cityy��State, Zip Code City, State,Zip Code <br /> ('I/S'1 2 6;Z, — C-)7S'3 O <br /> Telephone Telephone <br /> !' ANN =rt5 1.4 K/L 17 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s) Applied for: J c <br /> o <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit ° o <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P m <br /> Garage <br /> Structure Use: 1 o <br /> (family home/cabin, garage,addition, et . <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 oo' <br /> 2. Show the location of the well (W),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 q z C <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. C G 0 <br /> PLOT PLAN m lU^ <br /> a <br /> N <br /> D 0 <br /> C <br /> 0 <br /> Z <br /> F' <br /> ro o c w d a F Mm <br /> m - K' 'R; am RS. M <br /> < a ' H o 0. ro 3 <br /> 0 <br /> P £ p <br /> m <br /> N iiC <br /> $ : n [ M <br /> m : a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- 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 ro N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 rt $ <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 O o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 8 <br /> "' o <br /> m i 3 n <br /> SIGN HERE <br /> (si nature of ownerjpr building contractor) (date) E <br /> ZONING ADMINISTRATOR <br /> H_NM T <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o m <br /> 888 (ma <br />