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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W a a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisco <br /> in. H <br /> 0 <br /> lP 21, 6;lie o <br /> OV7NER a Print)—) ontractor or Surveyor or Agent <br /> 5-C 7 o <br /> .vd e h S>` W ry _ <br /> Address Address <br /> F9 d Effi c , Wls Agj'37 cG <br /> City, State,Zip Code City, State,Zip Code _ <br /> Telephone Telephone <br /> 'ki R r C>lfS6 h 49b e <br /> Emergency/Fire No. and Road Name u= <br /> D <br /> Legal Description (as Indicated on tax statement) q <br /> 7 <br /> Permit(s)Applied for: o ° <br /> Dwelling Addition Filling/Grading Camping Unit o r_, <br /> v <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: � n <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). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 <br /> C <br /> 3. Show dimensions In feet ofthefollowing:(a)buildingto all lot lines,(b)bulldingto center line of road,(c)building o Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. o 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m ( H <br /> dated by the owner. OD <br /> G <br /> to <br /> PLOT PLAN 1 <br /> M <br /> I <br /> v <br /> N <br /> O <br /> O � <br /> N <br /> o I1 �1 <br /> \I <br /> Z <br /> VX <br /> /I <br /> Icy <br /> (_ il' r4 :n�-t� mmvmrnn <br /> y <br /> C D y N <br /> N o 30 3 <br /> f T N M <br /> m <br /> g n c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c m A <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 informs- w m m <br /> w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this inf r- m a <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. g m g <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 N <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g m <br /> m A m <br /> 8 m <br /> SIGN HERE '�'������ / O 8 : <br /> (signature of owner or building pontractor) (d te) <br /> ZONING ADMINISTRATOR �i/)'I L'r lf\ 'I(71-11� <br /> TOWNSHIP PERMITS MAY BE REQUIREDN $ o o m <br /> $ $ 8 $ $ 88rmn <br />