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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W m o c <br /> APPLICATION FOR — LAND USE — PERMITS <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 <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 _ <br /> regulations off the State <br /> of Wisc[oyn/si(fj�r_ <br /> £ <br /> OWNE'F`(��le /e/P{m) �; // $�` Contra r rS a rorgent m �m <br /> Addres Address <br /> City, Ste t9 fZjp nrl C / j City,State,Zip Code } <br /> Telephone 'fi t / S 5 Telephone 1l6 7 7 � <br /> 11 E� rgenc /Fire No. and Road Namee <br /> r-p"hS �d��3- /��oC /� <br /> Legal Description (as Indicated on tax statement) <br /> o <br /> Permitr. <br /> Permits)Applied fo ° <br /> Dwelling Addition Filling/Grading Camping Unit ° g �' <br /> v <br /> 0 'o <br /> Accesso Buildin Sanitary Privy Subdivision ° <br /> Structure Use: ITAAAA,0 , VV - o <br /> rJ (family homelcabin, i6rage, addition, etc.) <br /> 0 <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). oo' <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 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 qo a- <br /> measurement to the ordinary high water mark of lake,stream,or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and o <br /> dated by the owner. <br /> � S <br /> PLOT PLAN L A - r M <br /> J <br /> RQ <br /> s <br /> tn' <br /> t of o <br /> W ° <br /> 2S' B o m <br /> ey f�}3 �- z- � G <br /> ND N (n 17 f� � DD � 9 <br /> k m, Dg4R. <br /> 0aw a. = a <br /> N <br /> G RAVEL- 2 0 A'D o f 8 i r�, M <br /> ca : m <br /> �n e 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- f S 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- yt m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this intor- j v 7S m In <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $m $ <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. lagree to permit county officials charged with administering county ordinances or other authorized person to have ': m 9 <br /> access to the above described premises at any reasonable time for the purpose of inspection. $ <br /> SIGN HEREH ` n <br /> (signature of o_ !`r or building contractor) date) c x <br /> ZONING ADMINISTRATOR / $ <br /> �±MMMt <br /> TOWNSHIP PERMITS MAY BE REOUIRED L" VnV 8 % o o tS rt <br /> $ 8888888u <br />