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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator - -0 c <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 o J <br /> regulations of the State of Wisconsin. o c <br /> m <br /> OWNER(Please Print) Contractor orSurveyo or Agrfl <br /> 1 m m <br /> Address Address-- <br /> e IP/- 6QL .` )/�z SL1 <br /> City, State,Zip Code City,State,Zips' 1 <br /> r <br /> Telephone Telephone <br /> 1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o , <br /> n G) <br /> 0 <br /> Permit(s)Applied for: �- <br /> m J <br /> Dwelling Addition Filling/Grading Camping Unit <br /> c <br /> Z o' <br /> Accessory Building Sanitary Privy Subdivision i <br /> ar — <br /> Structure Use: 5 <br /> (family home/cabin,garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 2 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 9' <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (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 if Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and o <br /> dated by the owner. C i <br /> PLOT PLAN +�%7 <br /> O <br /> I <br /> Cn <br /> �I <br /> rl �= <br /> v, I-3 <br /> o <br /> Z <br /> m o c m m n g m <br /> m <br /> ' z C a ' r <br /> = 9 <br /> ^ g3E: 1 ,20� e Wim <br /> 3i Zvi m <br /> i c <br /> 8 i Ami <br /> I declare that this application(including any accompanying schedule) a <br /> has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- «m« a <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I go $ <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 haveg <br /> access to the above described premises at any reasonable time for the purpose of inspection. ' m 8 g <br /> m 3 A w <br /> 2f f � <br /> SIGN HEREef' .0 <br /> (signature of owner or building contractor) (date) ; o x <br /> 8i <br /> ZONING ADMINISTRATOR TOWNSHIP PERMITS MAY BE REQUIRED <br />