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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m a o <br /> APPLICATION FOR — LAND USE — PERMITSo <br /> m <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and �2 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 3 a <br /> regulations of the State of W' onsin. w m <br /> ELI, _ (�(t 5e. 1 1� UUP �/�3f1Q a o <br /> OWNE^j.1e a Print) Contractor r Suryeyor or Agent o <br /> }5��1 Z LA+{P �f?Iyf lJ, 750� �{C 1�/{Z r LK. Ql�, <br /> Addres�s Addres .J I <br /> I—C)(PQI+ l a KD rnN . � D; rg'n AL— <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> n 0 <br /> Permit(s)Applied for: 0 It. <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <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 (N),septic tank(ST),and drainfield (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 <br /> r—I l/' <br /> - A <br /> N 1�j � <br /> m <br /> O H <br /> w <br /> Z <br /> I � <br /> o c iu m n a m <br /> n < . ,ZNo .0m3 <br /> Z o m .z : H <br /> S <br /> c rr <br /> O 2 C <br /> m c i C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S : n <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- _ N m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- r 8 nN <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 80 8 <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 $ g <br /> m 3 A u <br /> M N <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> A�1 I(J)f f <br /> ZONING ADMINISTRATOR 8 <br /> VI'Yl : <br /> TOWNSHIP PERMITS MAY BE REQUIRED Vila la n 8 o o S n <br /> 888888 $80 <br />