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61, <br /> 1( i,vl-�J <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <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 vrl <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 /> regulations of the State of Wisconsin. m m <br /> --L0J0sb e4t— Mlct ! i(?4g6E- f <br /> N (Please Print) Co actor or.$urveyor or Agent m° <br /> A&Jdres Addre <br /> AV Com. :�k1�(a_ m�? '] JA7h4j2(' Lc <br /> Ci State,Zip Code City, tat—S e,ZiJ ��Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> 0 0 <br /> Permit(s)Applied for: <br /> m ^ <br /> Dwelling Addition Filling/Grading Camping Unit o V"rnl' <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: °r <br /> (family homeicabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings(NB) and Indicate North (t). <br /> 2. Show the location of the well (W),septic tank (ST),and draiMield (DF). 5 n <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building Z `v <br /> measurement to the ordinary high water mark of lake,stream,or river. c a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A <br /> dated by the owner. C <br /> �I,�, � <br /> PLOT PLAN L <br /> CSr� J` <br /> V/ <br /> ;3 <br /> tISi ' l <br /> o <br /> N <br /> I <br /> I D <br /> is <br /> o n <br /> A. Ma's ao. N ai° 9 <br /> �^ < e o m ; <br /> o f T Ni Il <br /> a : <br /> In <br /> L" i 1 �9R I IC <br /> 8 a <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 informa- ? '� ' yy!!m: O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- i 7i ro N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.1 agree to permit county officials charged with administering county ordinances or other authorized person to have n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> N 3 A u <br /> M N <br /> SIGN HERE r=' <br /> (signature of owner or building contractor) (date) c <br /> ZONING ADMINISTRATOR 1 a��rC,l�T1 - 8 <br /> TOWNSHIP PERMITS MAY BE REQUIREDo o 8 m <br /> 88888888 (ma <br />