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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M c c <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m — <br /> TO THE ZONING ADMUIUSTRATOR:The undersigned hereby makes application for a Permit for the work described and H o <br /> located as showq herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> re ula"' s of thr State W�V js opsin. N <br /> o o6 <br /> J0 AJS(:)AJn <br /> F <br /> O �q (Pie a ri t) <br /> Contractor or Surveyor or Agent <br /> �Do �� /lion Toh o Rd <br /> Addr� � Address � <br /> City,State,Zip Cogo City,State,Zip Code <br /> Telephone Telephone <br /> Enter o. ("� aft is'/ Q0 /7 <br /> LegalDescription (as Indicated on tai sliflement) o (AO <br /> Q Z <br /> Permit(s)Applied for: o °< <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision m <br /> Garage nn <br /> Structure Use: L ��e er <br /> (fami home/cabin, 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). <br /> 2. Show the location of the well (W),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 .11 <br /> z Q <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 H <br /> dated by the owner. (1 , <br /> C YJ <br /> PLOT PLAN m <br /> o . <br /> a <br /> o = <br /> o RJ Q: <br /> m <br /> O y <br /> w I <br /> Z <br /> m <br /> a ap.� daNa = 9 <br /> Z <.af ? mo � ro ; <br /> o [ <br /> 21 y) M <br /> m <br /> w m � : <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o o [ In <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 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I v1g m 8 <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 ounty officials charged with administering county ordinances or other authorized person to have <br /> access to the abo describe remises t asonable time for the purpose of inspection. ; <br /> SIGN HERE v / w <br /> r H d <br /> (si atu of ow lding contractor) ( ate) c s <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PE MITS MAY BE REQUIRED p&"Orn'N 0 o o H8' m <br /> 088888888m <br />