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Burnett County 7410 Co. Rd. K, No. 102, Siren, Will 54872 Office of Zoning Administrator ; W o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3 <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 '^ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n 91 <br /> regulations of the State of Wisconsin. <br /> a o <br /> OWNERTease Prin oot aor or Surveyor o gent o <br /> r) m_ <br /> Ad r os Atl re <br /> tinIm ,n, I_iI- _5tk�l, pl br� r-0 <br /> (1LT R/8g� <br /> City, State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) v <br /> 0 <br /> Permit(s) Applied for: o <br /> o 1 �j <br /> r v, <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o (\ <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: N <br /> (family home/cabin, garage,addition, etc.) <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 o <br /> 2. Show the location of the well (W),septic tank(ST), and drainfield (DF). 3 <br /> 3. Show dimensions in feet of thefollowing:(a) buildingto all lot lines,(b)building to center line of road,(c)building Z oJ '� <br /> measurement to the ordinary high water mark of lake,stream, or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and ` `- <br /> dated by the owner. o <br /> C <br /> PLOT PLAN <br /> U , I3 s <br /> N <br /> y <br /> Tj <br /> f� <br /> Z <br /> z <br /> f <br /> M o c 1 m m o a Fm <br /> 9 < 'p" 'Z N O zo 120 <br /> Z ry p D Z 1 <br /> o F 0 a <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> 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 w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor : : 9 ro N <br /> I <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 8 0 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 /> access to the above described premises at any reasonable time for the purpose of inspection. ' w g 0 <br /> m i BA 0 <br /> N N O <br /> SIGN HERE <br /> H <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR \ I m Coal cfa11 <br /> TOWNSHIP PERMITS MAY BE REOUIRED L" N R c o 8 m <br /> 88 $ $ $ 888ai <br />