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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; ;/ c <br /> APPLICATION FOR — LAND USE — PERMITS 3. 3 _ <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the mm <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. w m <br /> ( iz-klo\ -3-e\useUy 6aw5-7- a m f <br /> OWTR (Please Print Corttracto or S rveyor or A em 9 <br /> 1 ++ i4 yn t; uJ QD 7 .7 7 V ,,,,es 44 2t� o <br /> Addel�s�'e <br /> city tat ,Zip X3Code City, <br /> VIA St e,Z' Cod Q <br /> - <br /> Telephone Telephone <br /> V 1 <br /> Emergency/Fire No. and Road Name t <br /> Legal Description (as Indicated on tax statement) o <br /> o / f <br /> Permits)Applied for: 0 <br /> o <br /> a <br /> Dwelling Addition Filling/Grading Camping Unit 0 <br /> Z <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° 0 (e' <br /> Garage N�( <br /> Structure Use: �%Tt4 1(t�o tm it V t U- - <br /> (family homelcabin, garagetaddition, etc.) 9-3 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) J <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 grainfield (DF). an 3 n <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building _ (� `v <br /> measurement to the ordinary high water mark of lake,stream,or river. o JA 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and N <br /> dated by the owner. C <br /> PLOT PLAN 110/ M 1 3 <br /> _ Q o y <br /> 0 <br /> m <br /> l�„ o <br /> 3 � <br /> N <br /> 0 <br /> o � <br /> N lLl} <br /> 1 <br /> G <br /> m O C c� m m A G F 9 <br /> p F 0 : r� ' M <br /> cN T <br /> ct� C <br /> i 8i ami € a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my no I- m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- yy��m In <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- 75 mut <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 80 $ <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 permit county officials charged with administering county ordinances or other authorized person to have O o , <br /> access to the above described premises at any reasonable time for the purpose of inspection. B R 8 R <br /> w <br /> 011 N <br /> SIGN HERE <br /> (signature of ow u' i�in ( ate) c <br /> ZONING ADMINISTRATOR // g <br /> TOWN HIP PERMITS MAY BE REOUIRED Yn'iN rrn 8 to o m <br /> 8 $ 888888rmn <br />