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o1q,('o 1 Y <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; m o 0 <br /> IE <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> z d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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 /> 0 <br /> regulations of the State of Wisconsin. w m <br /> m <br /> ALLAN s /A7s is �v/tGASo/ / L.d DuvcpN C�N�T n f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o (v m <br /> �7a o /6/ Au tia✓ y aZ�Y <br /> Address Address <br /> .t7iyooy�.�- /hN Ss3a y lr.F�osr.� .� SS'�P`i1 C? <br /> City, State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Emergenc Ffre No. and Road Name <br /> 6 7 0.E cc/4s o c¢ .co.v d <br /> Legal Description (as Indicated on tax statement) <br /> n 0 <br /> 0 <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading fGradin9 Camping Unit ° g <br /> � <br /> Z p <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: ALGA 66 Z Y y31 v 8 5 <br /> (family homelcabin, garage, addition, etc.) 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M W <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 1 a m <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 c <br /> measurement to the ordinary high water mark of lake,stream,or river. ° n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. <br /> C 1 <br /> PLOT PLAN /UO SF_rti - �}�. Gv�e-e' „ / Iall '� <br /> /rtuD LAKE <br /> V ~ <br /> v 1'l 1 0 0 <br /> GAEa6 <br /> t' 1c: <br /> Z <br /> V&VlLS 44Ae-f T ; '.00 $ a $ m <br /> m. Da� .'zaaN gmy <br /> mm <br /> Z <. ' 'z �� pro 3 <br /> o on TN : M <br /> = m <br /> N c <br /> g : rt9 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my <br /> know)-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- H 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 Burnett Wisconsin in determining whether to issue a permit. <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. Iagree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. ` <br /> � ap <br /> q b 8 <br /> SIGN HERE <br /> (si atur of owner wilding contractor) (date) <br /> i 8 i i <br /> ZONING ADMINISTRATOR y, <br /> TOWNSHIP PERMITS MAY BE REQUIRED N xn o o b m <br /> 88888888m <br />