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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U o` o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> u7 <br /> TO'fHE 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 M $ <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and _ <br /> regulations of t e State of Wisconsin. H <br /> /,/ � £ <br /> I nye / I/ J/Lf4�Y�9� � _ eC/ ii X'/'`s n <br /> OWNER (Please nntP— , f/ 11 " p! Contractor or Surveyor or Agent o o <br /> 1r�,� 1+ 5li �,S Fi`✓r' m <br /> Address ' ` Address <br /> VC�Jj_! <br /> nnl � <br /> City, State,Zip Code City,State,Zip Code 91 <br /> 1 <br /> Telephone Telephone Z <br /> Emergency/Fire No. and Road Name <br /> c <br /> Legal Description (as Indicated on tax statement) . <br /> n O <br /> Permit(s)Applied for: 0. <br /> w r <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> Zv <br /> 'o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> by <br /> Structure Use: 6-o rj r <br /> 0 <br /> (family h e/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). <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfleld (DF). 3 <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 <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 w <br /> dated by the owner. C <br /> PLOT PLAN <br /> I' <br /> s <br /> r <br /> N <br /> m <br /> N <br /> n <br /> U <br /> Z <br /> i <br /> Wc m m n a ? ir <br /> oa : 1Z : <br /> q _. N: r7, <br /> m c E C <br /> g : m 7 <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- i <br /> o : r <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- yy!�c t <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> matlon 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g o $ <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 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ <br /> r f ! 3 <br /> a <br /> SIGN HERE (signabke of own r o ullding contrutort (date) <br /> 8 <br /> ZONING ADMINISTRATOR <br /> M <br /> TOWNSHIP PERMITS MAY BE REOUIRED 9 98 9 o o t <br /> gg88888 <br />