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vf 1 �:Il <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3. <br /> m <br /> TO THE"ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <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. n <br /> regulations of the State of Wisconsin. o <br /> N d <br /> N �^ <br /> n � 0 <br /> E <br /> OWNER (Please Prim) Contractor or Surve or or A lent o A <br /> �5k,rl -'i�N Mzr ,y�rr, _ ,ccw,rATltT+ m <br /> Address Address <br /> 7S tf o 9' CO rn. (^r 1�'a f l r{CR 55 T3 t`E18d A <br /> City,Sip Code � City,`State,Zip Code <br /> mew ngwa <br /> Telephone Telepha <br /> tJ SVk01 I <br /> 715- l035-7t Ol —11 S- (o'SS'-Z�8Z � <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for t. -2e,44.£5TNTf oT"TrcE. r y o �. <br /> 0 <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> 2 0 <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage 1 <br /> Structure Use: l;1� ) r <br /> ^, o <br /> (family home/cabin, g6rage,addition, etc. II(yam\^,?J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) W <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 1 m <br /> 3. Show dimensions infeetofthefollowing:(a)buildingtoall lot lines,(b)buildingtocenter line ofroad,(c)building ' Q <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 o - (/ <br /> dated by the owner. C i 'i`t ' t <br /> PLOT PLAN m <br /> I <br /> }�I -0 <br /> CW < a <br /> PL <br /> ^'� Z <br /> fV � <br /> 0 I� <br /> D on a £ rmi <br /> m ^ D <br /> q m m o - 3 <br /> Z m Q 1 <br /> o T m M <br /> In <br /> L" € � 2 <br /> mom : i <br /> 8 ; i mW ' -y <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o ; <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 w m In <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- { v m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 (`j $ m 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. I agree to permit county officials charged with administering county ordinances or other authorized person to have ct o <br /> access to the above described pre ises at any reasonable time for the purpose of inspection. m . 3 $ x <br /> lD b N <br /> SIGN HERE (dale) <br /> ignature owner or building contractor) ( x E <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDu UN" , o o H8 m <br /> 888 8888rmn <br />