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&/L CDyy, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m a o 0 <br /> -APPLICATION FOR - LAND USE - PERMITS 3 <br /> TF 7HE-ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and s <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the L. <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 2 <br /> UA <br /> regulations of the State of Wisconsin. H <br /> C m <br /> Townshin of Seot.t, Daniels Plumbing & Heating Tnn n <br /> Ov�L%, y0(PI ase Print) Cc r r or u yor or Agent <br /> zuj �ounty Rd H ox <br /> m <br /> Address Address _. <br /> Webster WI 54893 Siren WI 54872 <br /> City,State,Zip Code City,State,Zip Code J <br /> 715-635-6363 715-349-5533 <br /> Telephone Telephone O` <br /> 28390 County Rd H <br /> Emergency/Fire No. and Road Name 2&g"XEMHp]MX)( prt of NWyNEr' S21 T40N R 14W <br /> Legal Description (as indicated on tax statement) <br /> O <br /> 0 <br /> Permit(s)Applied for: <br /> r V ' <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° '} <br /> Garage <br /> Structure Use: Existing fire hall/town hall r <br /> o <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 drainfieid (DF). 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 <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 m <br /> dated by the owner. <br /> C 0v <br /> PLOT PLAN m <br /> I <br /> 47 6 <br /> d � <br /> 4 6 <br /> SEE STATE APPROVED PLAN <br /> o <br /> 0 <br /> O y <br /> N_ IIL <br /> � I <br /> Z <br /> is <br /> > > n p i m <br /> m. 9 •� m e9 <br /> m 0 <br /> Z A p m ,z --1 <br /> f may: m <br /> N ' � C o <br /> $ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. c . a A 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. u m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g 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 nN o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m , <br /> T 3 n . <br /> m RA <br /> ' N N <br /> SIGN HER <br /> (signature of�owner or b Ilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED ry ra 8 <br /> 888 $ 88 $9 n <br />