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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Z <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m' o <br /> y <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � v, <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m �i <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulation of the State of Wisconsin. w m I <br /> h <br /> f-� L L 11/ / l� l f�^ 'r- Gr�T � , C 0 /V S T l? i-j c- T,•c> /\/ a '�0 <br /> OWNER (Please Print) Contractor or Surveyor or Agent m° ; <br /> Address- � '' _ Address <br /> J 0 0 A/ �= r2 VVl 5 4-1 C <br /> City, State, Zip Code f City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> ct <br /> Permit(s) Applied for: 0 c f� <br /> O <br /> Dwelling Addition Filling/Grading Camping Unit S . <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage _ <br /> Structure Use: A) <br /> (family ho /cabin, garage, addition, etc.) g <br /> �, <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 Yl <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). c <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). 0 o W <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building q Z <br /> measurement to the ordinary high water mark of lake,stream, or river. o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m y. <br /> dated by the owner. ; <br /> C <br /> p S_ k\J <br /> PLOT PLAN {V fA <br /> 0 <br /> I f O -75 <br /> syn zP <br /> �O �. ._-� � {k•x-per <br /> J S_ o l ) �1_f/1 0. <br /> O <br /> I 7� o <br /> G <br /> See <br /> _ Z <br /> SAS I� <br /> u , <br /> D <br /> m; n $- E m <br /> pT- f 0 Tm. M <br /> f <br /> Ake C <br /> i A A l i M <br /> I declare that this application(including any accompanying schedule)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 I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I 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 8 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 n v <br /> access to the above described premises at any reasonable time for the purpose of inspection. 3 8 w <br /> A <br /> XM— <br /> SIGN <br /> �_ <br /> HERE - f ='' a <br /> !signature ow er or ing contract <br /> ? : x : <br /> ZONING ADMINISTRATOR <br /> p NHM T <br /> OWNSHIP PERMITS MAY BE REQUIRED I FEB — 4 8 N 8 o 9 m <br /> 88888rmn <br />