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Ch1 (0))\�P , <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 'a 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and z U <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the mm <br /> Burnett County Land Use Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a illy-JJJ� <br /> regulations of the State of Wisconsin. o <br /> N YI <br /> Q.1 " n e LAl0GA1aTF_ G. G &'2 <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 765 c7k Cit. /3ob y (� <br /> Address Address g <br /> ',!2/nVL/14 & ' tic sy6319City, State,State, Zip Code City, State,Zip Code F" <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> o <br /> Permits)Applied for: o` <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision ° 0 <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> © Show the location and size of all existing buildings (EB) and,all new buildings (NB) and Indicate North (N). O o <br /> ® Show the location of the well (Vi),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)buildingtocenter line ofroad,(c)building <br /> on 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. m o <br /> C <br /> PLOT PLAN (ll <br /> M <br /> U1 <br /> co <br /> w � <br /> / �//✓� s <br /> 0 <br /> L T ° <br /> 4 <br /> 0 <br /> y ? <br /> c 7v <br /> Z <br /> goo mb <br /> Lll� G� f1J� o c m m a F m <br /> 3a a m s <br /> o3 <br /> z W o e i <br /> P m <br /> � �2 O <br /> 8 2 : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- Z4 o N <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ID m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. m <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I m <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 A N <br /> access to the above described premises at any reasonable time for the purpose of inspection. 3 <br /> m <br /> 3 ^ m <br /> SIGN HERE <br /> (signature of owner or buil ' g ont or) (date) n <br /> ZONING ADMINISTRATOR 8 <br /> ». <br /> TOWNSHIP P RMITS MAY BE REQUIREDom <br /> 8 <br /> ut ut ut . o . m <br /> $ 8888888m <br />