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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> m s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 00 3 Cc <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. }� /�n m C�7 <br /> JAcA Ilk ��LI�Ns t,r)P.r'I: - /I 117/�.K. �'r[�tv� a ' O <br /> OSEFIXPlease P00 / Cnntraaor o Sury or Agent 'o <br /> 11L f��( 11<, �r3rt Y . rS , gTor m I n <br /> Adt (�, '?& L 3K f � nr � . 171 55�1� AdbL�� � Y. <br /> City,St e,Zip Code ��' City,State,Zip Code <br /> Telephone Telephone 1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <_ <br /> ct <br /> Permit(s) Applied for: o 0- <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit 0 °» <br /> Z va <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: o <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). <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfleld (DF). 3 <br /> 3. Showdimensions Infest ofthefollowing:(a)bulidingto all lot lines,(b)buildingto center lineof road,(c)building � Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <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. <br /> PLOT PLAN <br /> M L. <br /> SJ <br /> t cchectCh <br /> - <br /> , C- <br /> V <br /> 0 <br /> O y <br /> N <br /> 1 <br /> Z <br /> I` <br /> ` f <br /> A o c m m n F m <br /> mx 5 M <br /> . <br /> 2 m' c. 5C 00 <br /> mm3 <br /> F o _I y i M <br /> c Cr In <br /> 8 m € M <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- 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 1 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. 8 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 4 <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m g X <br /> m 3 A a <br /> SIGN HERE <br /> (signature of owner or building contractoO (date) ~ ' o ? .9 <br /> ZONING ADMINISTRATOR <br /> N : <br /> TOWNSHIP PERMITS MAY BE REQUIRED U o o~b m <br /> 8999g988rm0 <br />