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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m <br /> APPLICATION FOR — LAND USE — PERMITS 3 TO 7HE'ZONING ADMINISTRATOR:The undersigned hereby makes application fore Permit for the work described and w <br /> a <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 other3 0 <br /> applicable County Ordinances and the laws and _ <br /> regulations of the State of Wisconsin. wm <br /> RO-Gk F`RAZGE SG,IsF w <br /> g o <br /> E.-fRj((pplease PrirnL <br /> `T to C0 = R0 Contractor or Surveyor or Agent o <br /> Address Address <br /> praaat)�ZU ifJ, . st1s3or <br /> C�i fState,Zip Q/ a�^ City,State,Zip Code �(— <br /> k�Qbr <br /> Telephone Telephone f} <br /> Emergency/Fire No. and Road Name IhhI <br /> �J <br /> Legal Description (as Indicated on tax statement) q <br /> Permit(s) Applied for: o R <br /> w 0 <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: <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). <br /> 2. Show the location of the well (W),septic tank (ST),and dralMield (DF). 3 t <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <br /> measurement to the ordinary high water mark of lake,stream,or river. o <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. M <br /> C <br /> PLOT PLAN <br /> m W <br /> ISRy <br /> I„ N <br /> n <br /> O <br /> 7 <br /> N Y' <br /> 0 <br /> m <br /> o � <br /> N Irf1�,jT� <br /> r I <br /> 1 Z <br /> _ 1 <br /> f <br /> o c a m o a g m <br /> oa DRr 5 am a <br /> Z g. � ? m80. m 3 <br /> p _ a <br /> m <br /> y C <br /> 8 : c : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a <br /> edge and belief it Is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- yy!!m h mO <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 go 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 <br /> access to the above described premises at any reasonable time for the purpos T 3 g <br /> A <br /> a wa <br /> w w <br /> SIGN HERE �+ n <br /> (signature of owner orb�y/i�tli g c %r) I O9�da ) <br /> / o . <br /> ZONING ADMINISTRATOR �` 8 . <br /> TOWNSHIP P RMITS MAY BE RE UIRED o o m <br /> _— f3�� 8 8 8 N <br />