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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator N v + z <br /> e e o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3, <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <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 Qf Wisconsin. H <br /> OWNNPPleaIl'Jd�Q'Pi(tt1 I` n / ContraaoJorSurveyo orAper� o <br /> ' '1 �' JW i-, tf5 :;+ : TDj. ! Q' 4 ! • it6/ �r m <br /> Adores sg \. <br /> Address , <br /> City, State,Zip Code A City,State,Zip Code <br /> ��I < x <br /> Telephone f Telephone <br /> yeQ <br /> Emerge cy/Etre nryeo. an R d Name <br /> N, inr ,lit—a k),I <br /> Legal Description (as Indicated on tax statement) 0 <br /> A rl <br /> Permit0s) Applied for: o <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> Z vo <br /> Accessory Building X Sanitary Privy Subdivision ° c <br /> m <br /> Garage �7,.,��,,�� <br /> Structure Use: `2n =ie'' <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). A <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 '11 <br /> Z e <br /> measurement to the ordinary high water mark of lake,stream,or river. o 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and y <br /> dated by the owner. M o <br /> C <br /> PLOT PLAN fp <br /> m <br /> l Od <br /> m <br /> -- CI o <br /> 0 <br /> t <br /> ( (n m v m r D D M <br /> y oc =. mmon <br /> m <br /> Z 0 a m Q 1 <br /> P f T N M <br /> O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c m m a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- wt!� m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- _ 8 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I —f i 8 m 8 <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 �, <br /> O . O <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m <br /> A v yA m <br /> SIGN HERE <br /> (signature of o(Aer or building contractor) (date) <br /> T o : <br /> ZONING ADMINISTRATOR ' I') <br /> TOWNSHIP PERMITS MAY BE REQUIRED N m <br /> 8888 8 $ N <br />