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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w m ; c <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and �2 H � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 14 n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and _ <br /> regulations of the State of/Wisconsin. m d <br /> 0aJrd1 1' . /`°G(fO44e / �04E'/' /'/rl/i' C 1 E <br /> OWNER Please Print) Contractor or urveyor or Agent v m <br /> t / BaY /S2 Rt 1 <br /> Address Addressr� <br /> �Uc� �i SS'g'f3 _ _Y��Prrc �i S�b'.3 7 ! <br /> j - <br /> City,State, Zip Code City, State,Zip Code ' ' <br /> 3.2 7- Fr73s' 5/72-2G9e`� f4,` <br /> Telephone Telephone <br /> // <br /> Emergency/Fire No. and Road Name <br /> S a'I / T j-7 R IF A L w- / <br /> Legal Description (as indicated on tax statement) o <br /> n 0 <br /> Permit(s)Applied for: o °_ <br /> J � \ <br /> Dwelling Addition Filling/Grading Camping Unit S Ci <br /> z <br /> v <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage .� U <br /> Structure Use: PLanE /Su4 Re007 <br /> (family home/cabin, garage, addition, etc.) _ I g <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <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 drainfield (DF). 3 <br /> 3. Show dimensions infest of the following:(a)building to all lot lines,(b)building to center line of road,(c)building80 Z c <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 ?�-, n• <br /> dated by the owner. C r. <br /> PLOT PLAN 50 M l S <br /> M �� n <br /> D,s�ance NoTTkSeR�f 0 y <br /> €B <br /> CR��ae ScrecnrJ �10�c/1 wit^ 10 <br /> (.J inlEer NI'anthan ^oem. 0_ <br /> East Read ani bou,Jl'i Z l•nr will v <br /> t "- <br /> ✓e movee) to r4 94.4E Jt� <br /> / e , zfi <br /> Q:36'nr. to 10f /me} Shewq <br /> J 8I£B z <br /> C ($ ,(�, }�Pr.sv 60 �aom lake 8 30 <br /> Gni rf DO - Sdo` Fn.. rmd Sfre&- <br /> f <br /> I <br /> I <br /> oC - mm o n � rn <br /> Q \ m K� a n o. a <br /> (' ✓✓ t5a ryD5 C00O 3 <br /> 0 S f", <. N � N O J <br /> V h N p i i f' m <br /> m c C <br /> 8 [ mm : i <br /> I declare that this application(including any accompanying schedule)has examined by me and to the best of my knowl- o � � m 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 I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnell Wisconsin in determining whether to issue a permit. I h 8 m <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication. I agree to per ' unty officials charged with adnimistering county ordinances or other authorized person to have <br /> access to the abov escrib l t <br /> premises any reasonabime for the purpose of inspection. m <br /> m V A u i <br /> SIGN HERE H a <br /> (at t re of ow{1 or uilding contractor) (date) p <br /> �� <br /> ZONING ADMINISTRATOR �2-7 rw" �� 8 <br /> % TOWNSHIP PERMITS MAY BE REQUIRED O N u o o mT <br /> � 88888888rmn <br />