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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m'V o/ a <br /> APPLICATION FOR — LAND USE — PERMITS3, <br /> d Q <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <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 _ <br /> regulations of the State of Wisconsin. <br /> ��yrr�p lit f 0harVlleid etido r4i <br /> gq.yyyyNER lease Print) Contractor or Surveyor or Agent o E <br /> WN TLAD NE <br /> dress Address <br /> Mll�l� PI DF'E MN tiscoE3 <br /> RiL <br /> City, State, Zi Code City, State,Zip Code <br /> (fin/Z) (019 - 3$l09 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> 7? <br /> Legal Description (as pIn�d� _icaated ontax statement) -Road o <br /> lvu <br /> Permit(s) Applied for: o 0 <br /> ' L <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit o ° <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: r <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <br /> 1A ^n <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) G W <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). X n <br /> 2. Show the location of the well (W),septic tank (ST),and dreinfield (DF). 3 <br /> an 3. Show dimensions in feet ofthefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building9 n <br /> measurement to the ordinary high water mark of lake,stream,or river. 80 o 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and `- <br /> dated by the owner. [A 0 <br /> C <br /> PLOT PLAN m <br /> 0 <br /> y <br /> o <br /> y <br /> i z <br /> OF UAA4 C Arice <br /> reyu� �llPd '_R04d/wa A <br /> QyV / r� W 7 7 1 4114 W i T�1 l: I 9 (/� N v 7i r D c. <br /> D p V <br /> V�r'+ m. D g� '�.a N n W pp <br /> c <br /> �(JAPc� �QecGJonJ,4��r Y a7 S�'c un N I .. <br /> 0 i XI <br /> m <br /> I declare that this application(including any accompanying sche8ule)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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I m g <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 r„ <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 80 <br /> ,1 3 <br /> N ; <br /> SIGN HERE <br /> H: a <br /> (signature of caner or building contra <br /> S ttlate c <br /> ZONING ADMINISTRATORSEF 9 g <br /> «ki rar � inoom <br /> TOWNSHIP WERrgIMAY BE REQUIRED Ug 8 8 8 8 8 8 8 rmn <br />