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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord M 0 0 <br /> ,APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the IyIS�ta'te of Wisconsin. �` y <br /> John t�t ,tw i f—�v Ug b'wv M o O <br /> f <br /> OWNER (Please P n1) Contr ctor o ry or r Agent ✓ �� o <br /> 443 fnrsnrt c7t 7� fnr <br /> Addres Address I <br /> L70Pb <br /> City, State,Zip Code City, State,Zip Code O <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n O <br /> — o <br /> Permit(s) Applied for: o ^- <br /> �' r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: r <br /> 0 <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). in c y <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building gZ `c <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 m <br /> dated by the owner. C , '1 0 <br /> 40 <br /> PLOT PLAN m <br /> � Up1 <br /> SL t <br /> �> <br /> 13 IY/ <br /> V ' N <br /> O <br /> P � <br /> O y <br /> .G <br /> A o c -D m y a F ma <br /> m. D a•� m n N a m <br /> P F0 : TZ . <br /> n <br /> � ^ m <br /> C <br /> g : m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> m 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- 0 m H O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- b"m <br /> mavon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. <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- IN <br /> plication. I 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. $e <br /> m E 3 n <br /> R ry p^p N <br /> H N O <br /> SIGN HERE «I a <br /> (signature of owner or <br /> building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> J wn�i .�i �rNNi,00 � m <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N N <br /> 888888880 <br />