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, > <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'U 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 2. <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the e m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> rreWisconsin. <br /> Dons of the State of Ww m <br /> iC o�Y P✓L S oLte�So O <br /> O1WN (Please Print) Contractor or Surveyor or Agent c r ', <br /> 119 m t <br /> AddressAddress <br /> 11��U'd J <br /> City, State,Zip Code City,State,Zip Code <br /> /&i✓ <br /> Telephone Telephone <br /> CYII - 2-5 G 1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o �' <br /> C) <br /> 0 <br /> Permit(s)Applied for: c <- <br /> �' r <br /> Dwelling Addition Filling/Grading - Camping Unit S ° <br /> Z 9 <br /> O O <br /> Accessory Building— s � Sanitary Privy Subdivision <br /> Garage <br /> i <br /> Structure Use: �n e e /y/rd s *02 7 0 <br /> (family home/cabin,garage,addition, etc.) <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). C) <br /> 2. Show the location of the well (W),septic tank (ST), and drain field (DF). in in 3 <br /> 3. Show dimensions in feet of the following:(a)building toall lot lines,(b)building tocenter line ofroad,(c)building <br /> an z - v <br /> measurement to the ordinary high water mark of lake,stream, or river. an o a <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. <br /> C <br /> PLOT PLAN } <br /> N <br /> O <br /> O <br /> 7 1 <br /> � kJ <br /> O y <br /> w <br /> I <br /> /� TZ z <br /> I <br /> f <br /> s e, 90� <br /> 3 <br /> a, g ainTe v a m <br /> li = ; <br /> C _� y( i Z C O O ,p <br /> o qq sz : M <br /> k o : ? y <br /> !'10 E c i m <br /> s <br /> mom : 5 <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- N m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 ac N [ <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 e 8 <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. [ 30 8 <br /> SIGN HERE . AeL «»+ <br /> (signature of owner or uilding contrac p (dale) \' p <br /> ZONING ADMINISTRATOR <br /> NNN � <br /> TOWNSHIP PERMITS AY BE REQUIRED <br /> �88888888vi <br />