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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 /> m o �. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 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 :. <br /> regulations of the State of Wisconsin. w m <br /> 0 <br /> �UC <br /> N NER(PI se Print Contractor or Surveyor or Agent m <br /> Addresg _ _ r Address <br /> lI' l <br /> City, State,Zip► <br /> Ziipp CCod`~e1l J� City,State,Zip Code , <br /> n (t� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name 1 <br /> Legal Description (as Indicated on tax statement) ° <br /> cr <br /> Permit(s) Applied for: 0 �. <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision ° m <br /> Garage �,.. / W <br /> Structure Use: � n I) / + I �� <br /> (family home/cabin,garage,addition, etc.) <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 draiMleld (DF). a 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 I `v <br /> measurement to the ordinary high water mark of lake,stream,or river. o 2LL <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m n m IM <br /> dated by the owner. C t <br /> PLOT PLAN a <br /> M <br /> ) U, <br /> � C:;r <br /> U = <br /> N <br /> 0 o. <br /> T <br /> O <br /> 2 Il <br /> 1 <br /> 0 <br /> r <br /> z <br /> . �)/0 f 4i li�✓/ / r "11i �U �/v <br /> M oc J. 0 Baa m <br /> 2. - S3z - a <br /> o 0m 3 <br /> _ of m2 . i <br /> 0 <br /> T <br /> m <br /> Tnf O O <br /> J_ 8 . i m m M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- y!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. I 8 m g <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- g <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have OiX o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m [ 3 8 <br /> B i B ^ <br /> SIGN HERE <br /> (signature of owner or building contrtrctOJ)` (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 88888888rmn <br />