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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> W O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 c <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 Wisconsin. <br /> 42 y LU t k; ,�S S E� F— c �� o <br /> f <br /> OW R (Please rint) Lj Contractor or Surveyor or Agent o <br /> Address Address <br /> Ua ; <br /> f 9 IP As 0iL W17 s'Vk9 <br /> City, State,Zip Code City, State,Zip Code <br /> 7/ S^ 7 1 <br /> Telephone Telephone Q ` <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) q — <br /> 0 <br /> Permit(s)Applied for: \ " a <br /> Dwelling Addition/_ Filling/Grading Camping Unit o V <br /> z <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage .� <br /> Structure Use: 11 - � /"G' /G�' ,(/A-Gl6'J <br /> (family home/cabin,garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) A <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show dimensions In feet ofthefollowing:(a)buildingto all lot lines,(b)bulldingto center line of road,(c)building z <br /> measurement to the ordinary high water mark of lake,stream,or river. a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and n � N <br /> dated by the owner. M 0 <br /> PLOT PLAN - <br /> m <br /> I - : <br /> N <br /> O y <br /> (/1 <br /> 1 V <br /> m o c m m D n F m <br /> = <br /> `' ^ a m <br /> a <br /> <. H' � mo � m0 <br /> 1 <br /> E 0 21 M <br /> ZN. O <br /> '` g m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- f 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 informa- <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 `) g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 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 /> m <br /> access to the above described premises at any reasonable time for the purpose of inspection. g <br /> yA w <br /> � ypp <br /> SIGN HERE —_ _ 3_ <br /> a : <br /> (sf ture f owner r ilding contractor) (date) R c x <br /> ZONING ADMINISTRATOR L/ <br /> N_ <br /> dry <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 u <br /> L <br /> J- 008000 <br /> 8 g g3Noo8 8 g 8 N <br />