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aurnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning AdministratorM 0 0 <br /> /APPLICATION FOR — LAND USE — PERMITS 3. <br /> d s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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 a <br /> regulations of the State of Wisconsin. w m <br /> J10/11c D6AlNA w4le✓e 0 <br /> �e <br /> J10/11 o <br /> OWNER PleasePri��tttyy- Contractor or Surveyorg <br /> or Agent m <br /> '7.2 D% Af✓d2",r. acv. m <br /> Address / Address <br /> 7 <br /> 'y, , P �- <br /> City, State,'Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> OAl-.6340 \laf�QQ LAA!£)one <br /> Emergpcy-/'FIreJJo. and Road ame \ �'1-- <br /> �e� 7o✓ .Col ( Ln <br /> Legal Description (as indicated on tax statement) <br /> o <br /> Permit(s) Applied for: 0 �- <br /> Dwelling Addition Filling/Grading Camping Unit - o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage <br /> Structure Use: F��f-/yam r <br /> T.-. (family home/cabin, garage, addition, <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) rA <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 (Sr),and drainfield (DF). 3 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building j - a <br /> measurement to the ordinary high water mark of lake,stream,or river. ° <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 0 <br /> PLOT PLAN ?S --�--_- m <br /> is S ��f� s�r✓w �� ° S y <br /> LJ m <br /> n <br /> r ' o <br /> o <br /> (,4 LlAA <br /> L <br /> r I` <br /> r E s � I <br /> / L Ile, do <br /> r , <br /> 6 <br /> j r <br /> m .0 Uc» rnr D V Mm <br /> .. m m n Dn <br /> m <br /> m <br /> L�Cl�l.r�. 6�P��l�• _ ! !!1 Y"ri °� wr�l iti (" �(.IYV('� /I ^ l bU(l i N m c C <br /> A4CP <br /> �- 8 : mm : n <br /> to <br /> I declare that this application(including any accompanying schedule)has been examined by me and the best of my knowl- o i 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- w m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- , ro u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ 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 <br /> 0 N o <br /> access to bove described premi san asonable time for the purpose of inspection. m 3 $ x <br /> A <br /> SIGN HER H a <br /> / (signa f#ne to 'Iding contractor) (date) <br /> $ <br /> ZONING AD INISTRATOR ' <br /> M_ <br /> TOWNSHIP PERMITS MAY BE REQUIRED 008000 <br /> r` <br /> $ 888 $ 8 <br />