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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d T o c <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H X5 <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 3 n <br /> regulations of the State of Wisconsin. <br /> c m <br /> (nAQ�1 �. �>CRl.I ASSt1'iT Ar.7NIEIf:. n G O <br /> F <br /> OWNEA ( e�a Print)�.0CT <br /> ��a Contra ori' Surveyor or Agent 'o (A, <br /> Address Address 1 <br /> O'Z)CJEA CA L r. SLI b <br /> City,State,Zip Code City, State, Zip Code <br /> c_t%cceyA ,,-r- -7t5-755-- a9O� <br /> Telephone Telephone <br /> Emergency1Fire N and Road Name C <br /> Lttr a PZ o� <br /> Legal Description (as indicated on tax statement) <br /> cl <br /> Permit(s) Applied for: 0 °- N <br /> m r <br /> Dwelling Addition � Filling/Grading Camping Unit S g <br /> v -1Z 'o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: 0.41& rJ <br /> (family homelcabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 � <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). C <br /> M 3 1 <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 c <br /> measurement to the ordinary high water mark of lake,stream,or river. o Z a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A H <br /> dated by the owner. <br /> C 4 <br /> PLOT PLAN IS <br /> M <br /> m <br /> 0 <br /> i O �Vjq co <br /> P <br /> �y <br /> J m <br /> fit <br /> i - 0 <br /> -75 <br /> 00461,3 0W6t1. I <br /> Z <br /> I � u � <br /> m <br /> m <br /> f. �' F 1 .X y-'✓ m. D a a n N m <br /> y N <br /> cam : m <br /> C <br /> 8i c : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m `� 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <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 <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- aN <br /> plication.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. m ; 3 88 <br /> m V A w <br /> SIGN HERE <br /> i e of caner or bu i contractor) o x <br /> cV' U V l.5 <br /> ZONING ADMINISTRATOR <br /> N <br /> TOWNSHIP PERMI MAY BE REQUIRED '� m <br /> 8888888m <br />