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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ' o c <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v O <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n <br /> regulatio s of the State of Wisconsin. w o <br /> a f <br /> OWNER(Ple3ase Print) y/ Contractor or Surveyor or Agent o <br /> '05 <br /> Avg- So Q —17 <br /> Addresdds LS yam/ Address <br /> City, State,Zip Code City,State,Zip CUde <br /> Telephone / _7a / 6�d> Telephone h <br /> Emergency/Fire No. and Road Name *Q9 Tohn1 s1/ <br /> � /`, / 4A ,6 ✓J ` 1 <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> Permit(s)Applied for: �- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit S g <br /> v _ <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision } <br /> Garage <br /> Structure Use: (d 570'1 n' / I '� 1 S ,5 S �f�Ki ^i M� 5 ' <br /> (family home/cabin,garage, ad Ilion, 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). O o <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (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 <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 A m. <br /> dated by the owner. C I 0 <br /> vi <br /> PLOT PLAN / L� d htj <br /> h W ) <br /> -31-- <br /> -^ <br /> o <br /> Z <br /> o <br /> o <br /> `- <br /> - — ---------- - -- -n N . m <br /> £e4 S1 m 2 C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> M 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- 'c w(,, m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. ! 0 mu, <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g m 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 /> C)N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m <br /> 82 <br /> V A e <br /> SIGN HERE _../ ~ t a w <br /> (signatu of ner or buil��contractor) ^= r1 <br /> ZONING ADMINISTRATOR <br /> ~ NMH <br /> TOWNSHIP PERMITS MAY BE REQUIREDI' t( � I 0 0 o'o 8' m <br /> t4M88888885, <br />