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6)7Clt ;,)�/ ) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ' 7 o c <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned here makes m <br /> 9 by application for a Permit for the work described and '5 m <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. o <br /> OWNER(Please Print) m o <br /> / p r ContContractor or Surveyor or Agent <br /> GX to <br /> m � <br /> Address A <br /> �^ Address G.C <br /> City,State,Zip CodeC L <br /> ity, State,Zip Code'-' 41 <br /> /) :7 Ao -g�51 <br /> Telephone L n , aqD Telephone <br /> Emergency/Fire No. and Road Name U) <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s) Applied for: a o Q� <br /> o � <br /> Dwelling Addition Filling/Grading Camping Unit o' <br /> v <br /> Accessory Building Sanitary Privy Subdivision o m <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) » <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 ( )y <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M o " 1 <br /> 2. Show the location of the well (yi),septic tank(ST), and drainfield (DF). 0 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 � o W <br /> measurement to the ordinary high water mark of lake,stream,or river. 11 o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A = <br /> dated by the owner. (A m: <br /> 0 <br /> 1 � <br /> PLOT PLAN C <br /> J <br /> 1 <br /> 0 <br /> � A <br /> m <br /> rn <br /> � _ <br /> �� 5[It[n7ro�5� <br /> q6 <br /> fn fn V rArDDp 9 <br /> ct /00 <br /> 2 o m ,c : 1 <br /> m <br /> Yi�g c <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 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 g 8 <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g g i <br /> SIGN HERE <br /> (signature f owner or building contractor) (date) � <br /> 7 0 ; x <br /> ZONING ADMINISTRATO 7K F Ai��'IL,�" 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED 5N $ o o m <br /> 88888888vi <br />