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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 0 <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 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 <br /> regulations of the State of Wisconsin. rn m <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> Addre s Address <br /> S/ , _/ /VI /iLN �J �n CJ <br /> City, State,Zip Code City, State,Zip Code <br /> ,27 9f3 <br /> Telephone Telephone ° <br /> Emergency/Fire No. and Road Name �f1 <br /> Legal Description (as indicated on tax statement) <br /> o lhUl <br /> Permit(s) Applied for: 0 <br /> `^ r <br /> Dwelling Addition Filling/Grading Camping Unit S °^ <br /> v <br /> Z p <br /> Accessory Building Sanitary Privy Subdivision o m <br /> Garage <br /> Structure Use: �� � — 0 <br /> o <br /> (family home/cabin,garage, addition, etc.) � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). on �3 v, <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building rnZ Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m y <br /> dated by the owner. C <br /> 1 <br /> PLOT PLAN �D m <br /> C/ Q ) <br /> r m <br /> 0 <br /> lI� <br /> N r I'7S <br /> o � IBJ <br /> e <br /> Z <br /> f <br /> o c m a F m <br /> m Da.� � nN amM <br /> < : '2 w o > > 3 <br /> Z m o m .2 t° 1 <br /> M <br /> m <br /> E O <br /> m c C <br /> 8 : i a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- gm <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- w m w o <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m $ <br /> further accept ail 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 /> C) <br /> access to the above described premises at any reasonable time for the purpose of inspection. $ 0 <br /> N V A m <br /> tp rt A <br /> SIGN HERE A – - d' s <br /> (signature ofowner or mg con or) I (d te) o x <br /> ZONING ADMINISTRATOR 8 <br /> urn`" <br /> TOWNSHIP PERMIT MAY BE REQUIRED u u 9, <br /> 88888888rmn <br />