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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn m A o O <br /> ?. >< <br /> APPLICATION FOR — LAND USE — PERMITS 0 3. s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q w Fri <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and o. �- <br /> regulations of the State of Wisconsin. <br /> 174 ityAIIJ P 9;/g1vp4,,E,,e cSel a m -�f <br /> OWNER (PleasePrint) Contractor or Surveyor or Agent o <br /> 9/ �✓. <br /> �ssDAm RD w <br /> 0 J <br /> Address Address <br /> Lv Et3s7-e2 W 85 � <br /> City,State,Zip Code City, State,Zip Code pc <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name Vl\ <br /> Legal Description (as Indicated on tax statement) o }z/ <br /> n 0 <br /> Permit(s)Applied for: c 'C <br /> w <br /> Dwelling Addition Filling/Grading Camping Unit o --. <br /> ro <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: �'4�b G` !/ / A d `/ r <br /> 0 <br /> (family home/cabin,garage,addition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank(ST), and drainfield (DF). 0 3 <br /> 3. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building � = v <br /> measurement to the ordinary hlg� water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted an arc Rea,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. oQI <br /> C t <br /> PLOT PLAN c M W <br /> C* <br /> VU �? <br /> � m <br /> -42-- <br /> Civ <br /> 42--Cw ) <br /> S rA rw V on DDO V <br /> � o c � > o a t m <br /> C 0 Zt <br /> e m < w C w <br /> 0 : _ j: M <br /> M <br /> C <br /> sclera that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ': o <br /> 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- .8 'm v, , <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 n 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 j v, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 8 <br /> / A ! ? 9 A in i <br /> SIGN HERE �"`�^� / /1 ` . N <br /> (sig ur of owns r ilding contractor) (date) <br /> ZONING ADMINISTRATOR g <br /> TOWNSHIP P RMITS MAY BE REQUIREDVI <br /> ro o o 9 m <br /> 8888888gum) <br />