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t <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c --a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c C <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ' <br /> Burnett County Land use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 4, <br /> regulations-orf the State of Wisconsin. y m <br /> f <br /> OWNER(Pleas7e Prim) Contractor or Surveyor or Agent m' <br /> Bo_X 2 � <br /> Address Address <br /> �Lrrn of Y /? <br /> ity, State,Zip Code City, State,Zip Code I `/ <br /> �2 2 - P ' ' ✓ <br /> Telephone Telephone G <br /> 2�-5o n /✓©�/SC l✓e. 3 �3 � l�a 'rs , t � aiiGy', tl <br /> Emergency/Fire No. and Road Name l <br /> Legal Description (as indicated on tax statement) .� <br /> n G) <br /> Permit(s) Applied for: 0 <br /> m l 1 <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> z <br /> Accessory Building Sanitary Pri Subdivision o <br /> Garage <br /> Structure Use: C a �, ( ^K 1 Al UOl <br /> (family home/cabin, garage, addition,etcJ <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). o <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(a) buildingto all lot lines,(b)bulldingto center line of road,(c)building Z c <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 m N Z <br /> dated by the owner. ; m <br /> C <br /> PLOT PLAN \ m <br /> \\\ <br /> - L — <br /> f <br /> fi pv ' C N <br /> O <br /> 4. ° <br /> q z <br /> I <br /> _ Yb +(es 90. gm <br /> m. � r� '—'a � "— � <br /> o m' — 3 <br /> 21 M <br /> J3 .0 its : i O <br /> t C <br /> . g i 'm i E y <br /> I 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 m N O <br /> tion contained in this application(including any accompanying schedule)and 1 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. 1 8 m 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 ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ru,' o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 0 <br /> ro V A u <br /> a <br /> SIGN HERE ✓".... L-..✓ �J— l._ <br /> M i n i <br /> (signature J of owner or building contracto (date) * <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED UK . o o In <br /> $ $ $ 88888rmn <br />