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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator u ' o a <br /> APPLICATION FOR - LAND USE - PERMITS3. <br /> 1Z <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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 3 <br /> regulations of the State of Wisconsin. m <br /> N <br /> f� d <br /> OVER (Please Print) Contractor or Surveyor or Agent o <br /> /o /-'cn 7i,,/ <br /> Ad ress Address <br /> Cil , State,Zip Code City,State,Zip Code <br /> 7- <br /> Telephone / Telephone I <br /> C 7�f 2� /SSS �}r,riInc <br /> Emergency/Fire No. andRoadName // / �L ,c/ -/ J <br /> �z' i"i io.^.F 5� %—_'[�N �c of <br /> Legal Description (as Indicated on tax statemen Tcin/ Tj!'���SS <br /> n O <br /> Permit(s) Applied for: o °- <br /> J < <br /> m 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: �,�/'n U <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 <br /> 2. Show the location of the well (yi), septic tank (ST),and drainfield (DF). 311 -6 v, <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building It Z `o <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 N <br /> dated by the owner. C ; <br /> I <br /> PLOT PLANLy <br /> m <br /> a_ <br /> i � N <br /> 0((yy ° <br /> Q <br /> O <br /> J <br /> O � <br /> Z <br /> x <br /> 1. <br /> G <br /> o c m m >> F m <br /> mgoo 0000 <br /> M <br /> P E J T M <br /> � ^ m <br /> N OoE 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- i m <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa- a m 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 8 m 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 have <br /> access to the above described premises at any reasonable time for the purpose of inspection. m o <br /> rov uFi ' <br /> m m <br /> SIGN HERE <br /> (signatu`re) owner or ildmg contractor) date) o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED u N 0 . o m <br /> a <br /> 88888 $ 8i <br />