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e"% L 6"-()q )i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator En d -0 ; c <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and '0H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <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. w m J <br /> c,N4,ZC4 "C Te <br /> n � <br /> OWNER (PI�seuPrint) Contractor o Surveyor or Agent o <br /> asaa � ( <br /> Address . Address , <br /> C4poo" e� Iw)S� . 5�p � I \> <br /> City,City,State,Zip Code City,State,Z ode <br /> d I <br /> Telephone Telephone 'r <br /> Isaar,[lAf <br /> Emergertpy/&FI(e No.k/ R�W mgt �eC r C) <br /> ���JJ `I JJ <br /> Legal Description (as Indicated on tax statement) o <br /> O <br /> Permit(s) Applied for: o �- <br /> u 0 <br /> Dwelling X_ Addition Filling/Grading Camping Unit 0 °^ <br /> v <br /> = o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage I r <br /> Structure Use: m4 - lJ IVa o <br /> (family home/cobin, 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). c <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (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 Z `o <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <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 <br /> PLOT PLAN Sed < L 'I ?0q <br /> . <br /> \ m I <br /> n <br /> v <br /> �r r /rM <br /> Nem dont "z_ u f Ie�S+ 2�` -rowrcun . <br /> KJ <br /> ° <br /> � Z <br /> � <br /> C�,�pI� kUY. vF /Uvj 4ome., <br /> � o� � mm0aS. 9 <br /> m <br /> A. DPa's WN g. m K <br /> < = 2H0 =1 <br /> e o A Z : M <br /> F o i l it ! i m <br /> Yn Zc : O <br /> 3 s ` ' C <br /> 8c : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S I i° i m <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- G):: O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 75 ro N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m g <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 ut <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 81 <br /> m 'Dnpnp �i <br /> SIGN HER <br /> H N <br /> (si u e of own r or buil g contractor) (date) s <br /> /�'f o : <br /> ZONING ADMINISTRATOR �h' IG � ': E g E <br /> TOWNSHIP PERMITS MAY BE REQUIRED pN N 8 o . 8 T <br /> X888888 8 <br /> �a-- <br />