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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator _ NI m o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> ;u o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and ii <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett bounty Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. <br /> N � <br /> �Z r /f ; //7 /S-,- G, //. "9(,/,cot <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> ,C 7 y IS�X '` m <br /> 7 /�'ok <br /> Address Address <br /> City, State,Zip Code City, State,Zip Code 1 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> 0 <br /> Permit(s) Applied for: oo 0 <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P a <br /> Garage a <br /> Structure Use: <br /> r <br /> (family home/cabin, garage, addition, etc.) ° <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). M n <br /> 2. Show the location of the well (1N), septic tank (ST),and drainfield (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 If Z <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and y <br /> dated by the owner. M of <br /> C ' <br /> PLOT PLAN <br /> CA 111 C = <br /> I <br /> Cy <br /> .c <br /> n <br /> f ' <br /> � 3E �� <br /> `? �o,,L <br /> NP fC- <br /> [ 4L <br /> E 11A J d IrVl <br /> ovm n > F 'run <br /> c 9o.� m' aN a �= M <br /> O = 3 <br /> ,p <br /> Z o <br /> P f m <br /> N O <br /> C <br /> 8 ' m <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl o M <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- m p <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- i i 'm <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have O <br /> access to the above described premises at any reasonable time for the purpose of inspection. . m <br /> m 3 <br /> SIGN HERE A —4-���� <br /> e ' <br /> (signatu�re of owner or building contractor) (diel <br /> ZONING ADMINISTRATOR ✓lam Flanl�t , 8 N <br /> TOWNSHIP PERMITS MAY BE REQUIRED SEP - 41992 1 1� N N N O O O m <br /> 88888888 (Mn <br />