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Bumett•County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m T c c <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 �' <br /> reulations of the State of Wisconsin. m m n <br /> �OL;0 G rei9 0 <br /> OWNER (PleasePrint) Contractor orSurveyor orAgent v m <br /> 1810 s, Vt��ort4 Rd � = a > <br /> Address <br /> Address <br /> V)1es .4-a 4ei;A-4, t Mm <br /> City tate,74p Code City,State,Zip Code <br /> la �8� -913 <br /> Telephone Telephone e <br /> 6I'sI-*I,e <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> c � <br /> Permit(s) Applied for: o` °. <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> X <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision o <br /> Garage <br /> Structure Use: <br /> mil ho garage, additi , etc.) <br /> e <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) S� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). <br /> 2. Show the location of the well (W),septic tank(ST), and drainfield (DF). 3 <br /> 3. Show dimensions infeet of thefollowing:(a) buildingto all lot lines,(b)building to center line of road,(c)building _ c <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 �C) <br /> dated by the owner. m ; <br /> C <br /> PLOT PLAN m <br /> � � o <br /> tr ' <br /> 0 Z IW <br /> O <br /> 61 <br /> o � <br /> a <br /> Z <br /> l <br /> � o� � dm � ag9 <br /> m. AFL gm y <br /> .2 m o Oro K <br /> P 0Z <br /> P TN y <br /> G) : m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- `�n vmation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g e $ <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.1 agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to thea ve described emises at any reasonable time for the pur se of inspection. 3 $ <br /> /I/Y✓�SOC f 'V _N p O <br /> SIGN HERE 2J``� - ! a <br /> (signaturree{bff'owner or buitdin ntractor) (date) <br /> ZONING ADMINISTRATOR ppp 1992 <br /> SEP 7 — y� <br /> TOWNSHIP PERMITS MAY BE REQUIRED ?a'9 a , 9 0 o NS r'tn <br /> 88 8888w <br />