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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d o <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 m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0. <br /> regulations of the State of Wisconsin. H m <br /> C <br /> n O <br /> F <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> CLO <br /> �'hL-Ad r�.ss Address <br /> 3 3 0� G le.K.no�-f Rd. _ <br /> State,Zip CodeCity,State,Zip Code <br /> it}cr � W� SC,40 <br /> L'L <br /> Telephone 7 Telephone <br /> Emergency/Fire No. and RoVad N e <br /> r-& /.- <br /> Legal Description (as Indicated on tax statement) 14rS-fw*j-y O P- I(. V 38'7 P 3(OF �--° <br /> Permit(s) Applied for. CL I T 3 g l fQo 14 t AGR ES $ 4 O ? o <br /> \X! y¢�q(?` .�e Lv 'f' /fo m o �y <br /> Dwelling —11 Addition Filling/Grading Camping Unit S �J <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage < <br /> Structure Use: (fib r�l I 5 <br /> (family home/cabin, garage,addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 a <br /> 2. Show the location of the well (W),septic tank (ST),and drainf laid (DF). on D3 N <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building it Z `a <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and in (-3 H <br /> dated by the owner. C <br /> PLOT PLAN 1 �I _ I �ILI w t <br /> m G a <br /> ' 0 <br /> O <br /> I Qj� o <br /> �s E12�j 1- <br /> .�. 30 O 7 � <br /> Ste` ��tr <br /> 40 Z <br /> sd><1 �fe �; ,n• <br /> th 6c ,nom <br /> n#e: ) <br /> o oc � mm � nF <br /> /�1,y/JIJf <br /> Z <br /> P0 <br /> O m <br /> m <br /> G> <br /> c c <br /> A : i a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to 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 detail and accuracy of all informs- »m» O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. $m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g o 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. Iagree to permit county officials charged with administering county ordinances or other authorized person to have O 0 o <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> AN ' <br /> SIGN HERE �fsfe� �= d <br /> (signature o er or ildin ractor) -- _ 'r�'�- 0 ' x . <br /> ZONING ADMINISTRATOR <br /> H <br /> TO NSHIP PERMITS MAY BE REQUIRED MAY — I0 <br /> T. <br /> �� - $ $ $ $$ $ N <br />