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Burnett (County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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 Wisconsin. N ° <br /> �erfw t SySye) 5.4Vj LoNSC Ge 0 <br /> WNER (Pleas Print) Contractor or Surveyor or A ent m Z <br /> 8133 �sGl � � fs Iter Or �de �95a be�IL> �AkQ <br /> Adtlress`clef Addre r ( d <br /> %t <br /> City State,Zip Code City, State,Zip ode <br /> d �tsn `mtNN .SA3.5 4Rg3 <br /> Telephone Teleph e <br /> toka — 84A4t— ` %g L(p <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s) Applied for: o o <br /> welling Addition Filling/Grading Camping Unit <br /> z <br /> v <br /> Accessory Building ---yyy---- Sanitary Privy Subdivision ° l <br /> Garage i I <br /> /A�)I <br /> Structure Use: ni 5 <br /> (family home/cabin, garage, addition, etc.) <br /> � r• <br /> a <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) O <br /> � <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank(ST), and drainfiaid (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 .�jl <br /> measurement to the ordinary high water mark of lake,stream,or river. o a a <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 /> y L <br /> L � s <br /> i r CGr�EXtlLan o��{r, f (� r J o <br /> o C ICN <br /> rr <br /> rbcpt <br /> �� o <br /> \-5 +y Po tl w, 4 5' �% � D w v`0 4 <br /> e 49 bt f75 )--r <br /> o J <br /> N S 4/C Z <br /> � Caar•wyn CurcH <br /> orr�f44ar2 S <br /> Wi r„ 60 Days- r <br /> kilI 1 mtn v (nrDD F <br /> C M W d a.a m a m a <br /> 590-1c9qc o m 3 <br /> N <br /> Z m 0 <br /> P E o m <br /> SCYV\LL Ao(�O U ` cis O <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o e a 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- w m N 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.11 i 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 u, <br /> access to the above described pKises at any reasonable time for the purpose of inspection. ` a 8 m <br /> m v A H <br /> SIGN HERE <br /> (signature nedin acto <br /> ZONING ADMINISTRATOR <br /> WNSHIP PERMITS MAY BE REOUIREDi1 M N N o698m" <br /> J 888888 <br />