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� r 1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 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 <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and o\ <br /> regulations the State of Wisconsin. <br /> 1111/ . 6 'Or't a )C/l -C / 1 1 t)lA�j l 1 c�/1P a ) o <br /> OWNER (131lease Print) Contractor or Surveyor or gem <br /> Address, ���-- Address <br /> 1� �L� �71(P"l ��d > �CT <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) <br /> � cit <br /> Permit(s)Applied for: 0 �- o <br /> m � <br /> p O <br /> Dwelling Addition Filling/Grading Camping Unit Z <br /> 0 <br /> Accessory Building Sanitary Privy Subdivision i <br /> Garage <br /> Structure Use o <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 �_ <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). O C ' <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). ,11I V <br /> 3 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 <br /> measurement to the ordinary high water mark of lake,stream,or river. c 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. C <br /> PLOT PLAN m > <br /> C� <br /> ch2CJ X 11 <br /> N <br /> r <br /> v o <br /> O <br /> ?. <br /> ' O � <br /> y <br /> iJ Z <br /> f <br /> 9o' 1mm � ag * <br /> _ g m <br /> a A <br /> nN �. = 9 <br /> ZO ! m .Z <br /> 0 <br /> = i € m <br /> g 8 c oki i Aa <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informa- 'G «m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 'm u <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to is a it. 1 8 - 8 <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.1 agree to permit county officials charged with administering county ordinances or other authorized person to have o o , <br /> access to the above described premises at any reasonable time for the purpose of inspection. 99 <br /> B [ '' a <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> _ R: p <br /> f 1i 8 E i <br /> ZONING ADMINISTRATOR "' m r+ ��i <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8 0 o 8 8 m <br /> f� 88888rmn <br />