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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c W <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m i.1 <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. H <br /> VAd/y w ,?A /1/DAGZ_ �� a F <br /> OWNEA (P <br /> lease Print� AdE ComraaororSurveyor orAgent o $ <br /> - `f/7 Scor �/ m <br /> Addr sAddress t <br /> ox YS %9G f M Al ss0zq v <br /> City, State,Zip Code City,State,Zip Code <br /> 4; — 537 - 02 Z7 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name r� <br /> Legal Description (as Indicated on tax statement) y <br /> J(1 <br /> Permit(s) Applied for: 0 C. <br /> Dwelling Addition Filling/Grading Camping Unit ° W <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision _ } <br /> Garage J <br /> Structure Use: r <br /> (family home/cabin,garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M , <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). o I <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 93 N" 1 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building inZ o <br /> measurement to the ordinary high water mark of lake,stream,or river. o a. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andm — S <br /> dated by the owner. C I I <br /> PLOT PLAN m UA ,� <br /> G � <br /> O <br /> g (ROD <br /> s <br /> v, <br /> o <br /> Z <br /> oc M.0 0Q. rrnn <br /> a <br /> o o 00 S <br /> 9 <br /> o f �O ;j M <br /> o <br /> M <br /> [ <br /> 8 <br /> E ' C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- o m 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- w m H O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i i `�ma <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I go 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.I agree to permit county officials charged with administering county ordinances or other authorized person to haven r"n' o <br /> access to the above described pr s at any reasonable time for the purpose of inspection. $ <br /> " 8nu <br /> SIGN HEREi G / yy _ _..� I N <br /> / a <br /> 00 <br /> (signature of owner or building cont c --- (date [ '. <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED . N 5 o ,o m <br /> $ " $ 8 $$ $ rn <br />