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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator -4 a <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 H O <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m `m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0. <br /> regulations of the S/t�ate of Wisconsin. <br /> EEC <br /> C <br /> OWNER (PleNase Print) Contractor or Surveyor or Agent o <br /> 3021 .7 „►y 35' v <br /> !1 j3Acores V V'\/ , ` 1 , ���Q Address <br /> Cityf l3�ta�1e7`Zip C d _w�l (� City, State, Zip Code 9�? <br /> J �n`7 <br /> Tel one Telephone I n <br /> Emergency/Fire No. and Road Name S <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s) Applied for: o ° <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> t <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: <br /> (family home/cabin,garage, addition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> r0 <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 drainfieid (DF). 3 <br /> 3. ShowdlmenslonsInfest ofthefollowing:(a) building to all lot lines,(b)building to center line of road,(c)building � Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m y t 1 <br /> dated by the owner. <br /> C <br /> PLOT PLAN m (51 <br /> UJ <br /> W <br /> All 19 hyo <br /> ° I� <br /> o <br /> N <br /> Z <br /> oc -9mm �nF m <br /> O < :25 : -Z N O 3023 <br /> 3 <br /> Z i4 -O' <br /> P F Z TVl S <br /> C <br /> 8 : a ; c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know l- 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 informs- h o O <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 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 so- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 3,+ Y <br /> m <br /> access to the above described premises at any reasonable time for the purpose of inspection. g <br /> m [ 3 n <br /> m ro a <br /> SIGN HERE y4 41 94L.I. <br /> (sip lure of owner or building contracto (date) e <br /> ZONING ADMINISTRATOR ` 8 <br /> TOWNSHIP PERMI S MAY BE REQUIRED N . o o 99 m <br /> 8 $ $ 8rmit <br />