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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m c c <br /> APPLICATION FOR — LAND USE — PERMITS • <br /> N� <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permitfor the work described and v C <br /> located as shown herein. The undersigned agrees that all work shall be done In accordance with the requirements of the � $ <br /> Burnett Courtly Land Use Ordinance,Sanitation Code,and with all other applicable County Ortlinancesand the laws and _ <br /> regulatio of the State of Wisco in. <br /> 12 0 <br /> OWNER (Ple P ) Contractor or Surveyor or Agent o <br /> a�Z'f�t anode Sul,. led <br /> Address ,✓ / Address <br /> City,State,Zip Code City,State,Zip Code <br /> TelephoneTelephone �- <br /> ';�V In *,� <br /> Emergency/Flre No.and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> o <br /> Permh(s)Applied for: o 0 <br /> J C. <br /> a � <br /> Dwelling Addition Filling/Grading Camping Unit c <br /> Z 9 <br /> a <br /> Accessory Building _� Sanitary Privy Subdivision m <br /> araage' jr .,C IacStructure Use: ( X <br /> (family home/cabin,garage,addition, etc.) /a C�� <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 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 3 <br /> measurement to the ordinary high water mark of lake,stream,or river. . o FL <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and n N. <br /> dated by the owner. C 0 <br /> PLOT PLAN <br /> Ny, <br /> nif. Qfse 'c✓ a f <br /> �7 o` <br /> C�6lerf brn� <br /> '� Det? ole �r.n. <br /> 0 <br /> tl o <br /> l'\ <br /> 1`I �dv0.•)� i�` � <br /> o � <br /> y{Ind <br /> Lin I� <br /> 77 f <br /> 1(T' , a ocT m nntppV <br /> o gym ; <br /> O@ u' <br /> Y j i �il•� i i � <br /> Vida L4.tE/•f. � m <br /> I declare that t Is application(including any accompanying schedule)has been examined by me and to the best of my knowl• . � <br /> edge and belief It is true,correct and complete.)acknowledge that I am responsible for the detail and accuracy of all informa• }g± mr p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. <br /> motion I am providing will be relled upon by the County of Burnett Wisconsin in determining whether to Issue a permIt.- <br /> further accept all liability which maybe a result of the County of Burnett relying on this information I am providing in thio ap• E <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. ` ? <br /> r A <br /> e : <br /> SIGN HERO <br /> (signature of o n or In ate) <br /> o : sr [ <br /> ZONING ADMINISTRATOR c tr or) 8 ' <br /> TOWNSHIP PERMITS MAY BE REOUIRED $ 'o o m <br /> 8888888rn <br />