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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W m o a <br /> M. 3E <br /> APPLICATION FOR - LAND USE - PERMITS m <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w o 1� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 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 State of Wisconsin. o � <br /> m m <br /> A-116AVETN sea• a <br /> INE tP�rriinj Contractor or Surveyor or Agent o <br /> d , <br /> Add <br /> ass <br /> EG Address <br /> Z - �5 <br /> Iry, tate,Zip Code City,State,Zip Code <br /> i <br /> Telephone Telephone .J <br /> Emergency/Fire No. and Road Name <br /> 1 <br /> Legal Description (as Indicated on tax statement) �i o <br /> Permit(s)Applied for: ? o } <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit o °— <br /> z <br /> o <br /> Accessory Building Sanitary Privy Subdivision � <br /> Garage <br /> Structure Use: Orl <br /> 0 <br /> (family home/cabin4rage,add8ion,)atc.) � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <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 drainfield (DF). C 3 <br /> 3. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building z 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 and A = <br /> dated by the owner. ffl o <br /> C <br /> PLOT PLAN <br /> Rl"ACtiA16o <br /> N <br /> 0 J <br /> m J <br /> 70 <br /> O N <br /> w <br /> ^ 1 C <br /> z <br /> �o <br /> zz-- X/��r�� <br /> J � <br /> T <br /> 2. M <br /> CCS - <br /> 52 ; <br /> o t T y <br /> V m <br /> s : <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and ballet it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ m <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 43 i g m g <br /> further accept all liability which may be a result of the County of Bumett relying on this information I am providing in this ap. <br /> plication.1 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. ` n <br /> /J D : <br /> Al ' <br /> a ap <br /> SIGN HERE <br /> (signatur of�owner or building contractor) (da ) c x <br /> ZONING ADMINISTRATOR , IIrYl Fi'_f}I�)i017 g E <br /> TOWNSHIP PERMITS MAY BE REQUIRED {{�!! iU <br /> 8 8y� <br /> 7 . 75m <br /> 8 $ 888rmn <br />