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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (A 0 c c <br /> APPLICATION FOR — LAND USE — PERMITS 3. 0 <br /> m o <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 - m <br /> Burnett County'Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. m m C <br /> F�Eb AeIC �� ie a f <br /> OWNER (Pleas Print) y' y P. Contractor or Surveyor or Agent v �, <br /> Add es �.52�1 &)'6e Address <br /> City,State,Zip ja�el /�/� City, State,Zip Code <br /> Telephone Il��jj�� !� Telephone , <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) ° r <br /> Permit(s)Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit S 1) <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P 3 <br /> Structure Use: �� � � � ' '� c <br /> (family home/cabin, garage, addition,etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) A J <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 draiMleld (DF). a m <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building .� Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. 0 0 <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. C I <br /> PLOT PLAN <br /> '/ <br /> I v <br /> h_ez- <br /> `tr . <br /> N <br /> N :F1 <br /> N <br /> r I� <br /> Z <br /> C� <br /> G <br /> � <br /> c: <br /> m <br /> < 0 o =0 ; <br /> Z o e ,Z - 1 <br /> P TNM <br /> c� rn <br /> me c <br /> m a <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.1 acknowledge that I am responsible for the detail and accuracy of all informs- i w 0 O <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. 1 i $ 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 n <br /> access to the above d 'bed premises at any reasonable time for the purpose of inspection. m 8 <br /> 0 � ypa '. <br /> M a O i <br /> SIGN HERE w n [ <br /> (signature of owner or budding contractor) (date) <br /> ZONING ADMINISTRATOR //,Yl <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> $ $ $ $ $ $ $ $ rme <br />