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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; - o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> s <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 e m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and a <br /> regulations of the State off Wisconsin. <br /> I /� <br /> I(N7� �G�I�fp Ia l�+t"T Vlf <br /> OWNER (Please — ContractoRS . -A- iS,urypd o, +eo A <br /> Adam Address <br /> City, State,Zip Code City,Staid,Zip� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) \ <br /> n 0 <br /> Permit(s)Applied for: 0 0_ <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o- <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision o a <br /> Garage <br /> Structure Use: r <br /> 0 <br /> (family home/cabin,garage,addition, etc.) <br /> 1A <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). <br /> 2. Show the location of the well (W),septic tank (ST),and draintield (DF). 3 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 .� Z `v <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 and y <br /> dated by the owner. C <br /> PLOT PLAN m Z <br /> I- <br /> O C <br /> , 0 <br /> IN <br /> J <br /> O y <br /> w <br /> r <br /> Z <br /> i <br /> f <br /> o c m m a A <br /> m a�� anN nm = <br /> <_ ``i : � H o > > 3 <br /> Z . � m ,Z : 1O - <br /> o T N _ <br /> g mA <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- rr�� S ' � n <br /> n <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 'vV c H ro H r <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 <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 n "' o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ N <br /> m 3 ^ <br /> SIGN HERE ` J' <br /> (signature <br /> eoof'owner or building contractor) (date) c x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDSn^ o o 'r88888888 ( <br />