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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS <br /> m <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m Tl <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m 1 <br /> Burnett County Land Use Ordinance,Sanitation Cade,and with all other applicable County Ordinances and the laws and <br /> regulations of the St a of Wisconsin. w m <br /> w <br /> �av;dL rC' � o <br /> OWNER (Please�rirtt) Contractor or Surveyor or Agent o <br /> ,,) �. .��1'Prk1= <br /> m <br /> AddrrAddress <br /> r� ' <br /> p7mi , n <br /> City,$tate,Zip Code City,State,Zip Cade <br /> Telephone Telephone <br /> S <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as Indicated on tax statement) o rn <br /> Permit(s)Applied for: o 'C <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Butldin Sanitary Privy Subdivision ° <br /> Garage <br /> I � <br /> Structure Use: i �1 ��1 ly 611 I o <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <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 drainffeld (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building z o <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 CJ j <br /> dated by the owner. o <br /> PLOT PLAN <br /> Z <br /> 9 J <br /> 1 00 <br /> 1 <br /> 4 <br /> 0 <br /> O y <br /> w <br /> I-C <br /> pr Z <br /> 1 D <br /> F <br /> i; <br /> g c m m o n V m <br /> 0 33 M <br /> lyssa' m <br /> O £ TZ 00 y M <br /> c : <br /> In <br /> fix ; L7 � O <br /> ro c i C_ <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 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- w 0 ! 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 8 m 8 <br /> further accept all 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 /> access to the above described premises at any reasonable time for the purpose of inspection. B 3 8 , <br /> V AA N <br /> m O . <br /> M N <br /> SIGN HERE : H n <br /> (signature of owner or building contractor) (date) s <br /> Q . <br /> ZONING ADMINISTRATOR I,)' �� � ��}�� x 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N o m <br /> 8888 m <br />