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r <br /> dumett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m c o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 LP <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and { allregulations of the State of Wisconsin. <br /> yJ 1 LU AM 1TZU L5 S�t >f n m �, o <br /> OWNER Please Print Contractor or Surveyor or Agent o LA <br /> Q <br /> t>o�tA m <br /> dresS 5.5105 Address <br /> T UL . Mt4. <br /> City, State,Zip Codd City,State,Zip Code <br /> 1 <br /> Telphone Telephone 7j <br /> 002 I�IWti 11 — <br /> Emergency/Fire No. and Abed Name <br /> Legal Description (as Indicated on tax statement) <br /> � L7 <br /> Permit(s)Applied for: <br /> Dwelling Ad illing/Grading Camping Unit <br /> v 1„ <br /> 0 o <br /> Accessory Building Sanitary/� rivy Z+ <br /> Subdivision ° m <br /> Garage <br /> r� <br /> Structure Use: --- _ <br /> (family home/cabin,garage,addition, etc.) <br /> C ,7 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <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 drainfieid (DF). 3 v <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 0 - t `v <br /> measurement to the ordinary high water mark of lake,stream, or river. .. a <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. C y <br /> I <br /> PLOT PLAN „ LQI� �y,/t m J G <br /> ATMCokk > <br /> St) 0 0 <br /> m <br /> ILA <br /> a <br /> 77 <br /> w <br /> Z <br /> J D <br /> o c m m n a E ma <br /> c ag� Ow ok mM <br /> < : 'Z N O J m 3 <br /> Z O O 1 <br /> 8 : mG i <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- i_g m 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- y! G): <br /> O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- (.! <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 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 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g <br /> MM YAC <br /> SIGN HERE 8 <br /> a <br /> (signature of owner or building contracto (date) 8'� - <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED $ —06 8 Mm <br />