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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm a a <br /> APPLICATION FOR — LAND USE — PERMITS m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H �\ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m --- <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulattiionss of the State of Wisconsin. , y/�//� ^. ' H ° <br /> � f ap-d ��I I� XJl . I����GU o O <br /> OWNER (Plea ePrint) ComractororSurveyor rAgent o ,1; <br /> �� E. 6�a ��la ErI"� m <br /> Addre s }� Addrs <br /> LAv <br /> Ke t-test � <br /> - - L604s— fxx�ner d)�L RDS ;_1 <br /> City, State, Zip Code City,Statb, Zig p Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> nL7 <br /> Permit(s)Applied for: o ° <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: <br /> (family home/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 drainfield (DF). C 3 <br /> 3 .Show dimensions in feet of thefollowing:(a) buildingto all lot lines,(b)buildingto center Ilne of road,(c)building z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. C J)J <br /> PLOT PLAN m <br /> UJ <br /> 1 <br /> <� o <br /> e r <br /> m <br /> o <br /> Id <br /> � Z <br /> �1 <br /> onmm �a � <br /> �. nm am y <br /> '^ < < ' .zao � m 3 <br /> M <br /> Y ' ! eg i <br /> fig ; ate : <br /> 1 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- i M m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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. 1 g m 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 0 i7 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ <br /> m v A � <br /> N in 8 <br /> SIGN HERE i i a i a i <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR 'J 1`Y) <br /> TOWNSHIP PERMITS MAY BE REQUIRED 3n $ o o m <br /> $ 88 $$ 888rmn <br />