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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator .w f c <br /> APPLICATION FOR — LAND USE — PERMITS o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the M c <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> o <br /> regulaQons of the State of Wisconsin. w m <br /> /9ye /- /Jj/yg f <br /> n O <br /> OWN P nnt) Contractor or Surveyor or Agent v e' <br /> eG/u FF m <br /> Addr ss 117 Address <br /> SLl <br /> city, �%�Ip fygd - City,State,Zip Code I <br /> Telephoner/X/ ' Telephone <br /> � — L <br /> Enter en`t(Fire and o am <br /> � y'�:°r �i �ffe /� 74jAl2/G r c/ <br /> Legal Description (as Indicated on tax statement) <br /> o — <br /> Permit(s)Applied for: o <br /> Dwelling �. Addition Filling/Grading Camping Unit 0� <br /> Z o <br /> Privy Subdivision Accessory Building Sanitary <br /> Garage } <br /> - Std PVI T)I T- q - 0 ^ <br /> Structure use: <br /> (family home/c n,garage, add' ' n,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 <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfield (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 o <br /> measurement to the ordinary high water mark of lake,stream,or river. ° n I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m N <br /> dated by the owner. ppp C o <br /> PLOT PLAN � IMII (� <br /> 0 <br /> I <br /> N <br /> O <br /> I , <br /> a # 1 <br /> Z <br /> m o c c T m m o a g m <br /> N m <br /> P fo rvi: a <br /> In <br /> g m _ <br /> 8 6 <br /> e m � <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- om <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- u mr O <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- f m <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ o $ [ <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- pt <br /> plicalion.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. • $x <br /> B $ A <br /> N <br /> N w <br /> SIGN HERE a <br /> (signal of owner or building contractor) ", (date) ' <br /> ZONING ADMINISTRATOR ` ` . ` <br /> w08n <br /> p <br /> TOWNSHIP PERMITS MAY BE REQUIRED r c p 8 <br /> n <br /> T $88u <br />