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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator in 'a \ c{ o <br /> APPLICATION FOR - LAND USE - PERMITS 0 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. N w <br /> �/lnwl <br /> OWNER asePrint) Contractor or Surveyor or Agent o A <br /> Voji-V Z9 <br /> Address ' <br /> Address <br /> Ci GState, <br /> JlZip Code City,State,Zip Code <br /> I� <br /> Telephone Telephone <br /> A*'-A 7 2 7 X l4. �_LYioirf 3 rn �o% 6Vj9.&LALd LAK <br /> Emergency[FIre No. and Road Name <br /> PGL ' V4. /G . 3l . y7em) Lor 3.4 eSA ✓ / P /Z,2 /'Cau Lor sem) <br /> Legal Description (as Indicated on tax statement) o <br /> n L) <br /> Permit(s) Applied for: 0 0 <br /> r <br /> Dwelling Addition LIf Filling/Grading Camping Unit c ° Ynl <br /> v <br /> z a <br /> Accessory Building Sanitary Privy Subdivision ° � <br /> Garage <br /> Structure Use: 1442 4 0QrrgrME,0 410 ('AAin1 _-yr�.esf'4l L�.✓Ly . o <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <br /> 1. Show the location and size of all existing buildings (ES) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST), and drelnfield (DF). 3 <br /> 3. Show dimensions Infest of thefollowing:(a)buildingto all lot lines,(b)buildingto center line of road,(c)building Z o <br /> measurement to the ordinary high water mark of lake, stream,or river. o a <br /> 4. it separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 0 y <br /> dated by the owner. M 0 <br /> C I <br /> PLOT PLAN �� m <br /> W <br /> 1� <br /> 0 73 <br /> N <br /> 0 <br /> W 'war r <br /> 7m]lu <br /> h <br /> ro <br /> PGL >4� YD• iG .3/ <br /> cer3q Csirl r/ s /' i62 Cho [o- <br /> p <br /> `. o c m m a F m <br /> m. aa� aaAa . M <br /> j a <br /> 0 @@ m •2 1 <br /> O F : T y m <br /> C_ <br /> t <br /> I declare that this application(including any accompanying schedule)has been examined by me and the best of my knowl- � S : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the defdit and:accuracy of all informs- — !� m H S O <br /> tion contained in this application(including any accompanying schedule)and I further declar@.that l recognise that thisinfor E 25 mini <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determine ether toissuea permit. g a 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this infor I am providin in this ap- i , N , <br /> plication. I agree to permit county officials charged with administering county ordinances or t r utlCr�e��lave� u, <br /> access to the above clescriW premises at any reasonable time for the purpose of inspecti ` a g g <br /> n <br /> V A x <br /> Zg SIGN HERE > <br /> (sign ure or e o ? <br /> ZONING ADMINISTRATOR - -- ' ` g <br /> _ � NN� <br /> MNM � <br /> T NSHIP PERMITS MAY BE REOUIRE J ) u m $ o o 8 m <br /> sssassssy <br /> ` j J <br />