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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. 0 <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m „J <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a Q <br /> regulations of the State of Wisconsin. w m <br /> L-M ick l%No <br /> 0 EORPIj7e,PP,e' . �V Contractor or Surveyor or Agent <br /> m <br /> A_Qdress �n�- MN - ��� Address <br /> City, State,Zi lCode rC City,State,Zip Code <br /> Telephone Telephone �`� <br /> , <br /> Emergency/Fire No. and Road Name S\ <br /> Legal Description (as indicated on tax statement) o <br /> n O <br /> O <br /> Permit(s) Applied for: 0 ^. <br /> m r <br /> Dwelling Addi Illing/Grading Camping Unit °— <br /> v <br /> Z o <br /> Accessory Building Sanitary Ivy Subdivision <br /> Garage 1 <br /> �h <br /> Structure Use: 5 <br /> (family home/cabin,garage, addition,etc.) Mill �J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X W <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). C oo' <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 11 <br /> 93 v <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 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. C <br /> PLOT PLAN m <br /> v <br /> z <br /> N <br /> M <br /> �I <br /> CO <br /> am <br /> 0 <br /> �y <br /> - Z <br /> 0 c m m o a F T <br /> m - a'* '-.n m C = M <br /> c m < . 'R .10, 2 .c3 <br /> o mO ` m,Z M <br /> a <br /> = m <br /> N ' OS ' C <br /> mA ` ' M <br /> I 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 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- m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 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 O P O <br /> access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m m A m <br /> SIGN HERE <br /> '614'^""` J ~ H m 8 <br /> (signature of owner or building con or) r (date) c x <br /> ZONING ADMINISTRATOR J la�r 2 g <br /> TOWNSHIP PERMITS MAY BE REOUIRED o o t5 m <br /> 8888 ai <br />