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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m <br /> TO T19E ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the w <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. H m <br /> MccrV1n nyo e �Pl c f <br /> OWNER(P ase Print) Contractor or Surveyor or Agent o m' <br /> ress Address <br /> �1e11 kkK'e , a. S416'7/ _ <br /> City,State,Zip Code City,State,Zip Code <br /> 7/5- q - �' 9� L — <br /> Telephone Telephone y ` <br /> D. ,ti>< a 930 - - <br /> Emergency/Fire N and Road Name S <br /> swY / ITScc � 7� T3gi/ - �ly� <br /> Legal Description (as Indicated on tax statement) <br /> 0 0 1 <br /> Permit(s)Applied for: 0 <br /> Dwelling X Addition Filling/Grading Camping Unit ° o <br /> Z o ) <br /> Accessory Building Sanitary Privy Subdivision ° } <br /> Garage r <br /> Structure Use: n � i r�1zt/ �( 1n <br /> (family homeicabin, garage, addition,etc.) ,B <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O <br /> 2. Show the location of the well (W),septic tank(ST),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 Z v <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an archhect,engineer,builder,contractor,etc.,the plans must be signed and A <br /> dated by the owner. C <br /> �J <br /> PLOT PLAN a <br /> m cN <br /> 4 Y 1 S7in y a. m CM <br /> bufl�tnC A C I�- <br /> S /Tc . <br /> Sw - SUI �ec � 7 rtun 3$ <br /> Q <br /> N <br /> P ' <br /> a <br /> I Z <br /> s o� <br /> P <br /> i <br /> 11 V" <br /> v � � <br /> �tirSn <br /> at l-L> rrA./ �_ m o c a r o a F T <br /> Z .z m 05i5 ; <br /> o .m a @ 1 <br /> o <br /> F , , c2 m <br /> C <br /> 8 : m; m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ( 4 , 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! m [ O <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 <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.I agree to permit county officials charged with administering county ordinances or other authorized person to have Cf o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ $ <br /> B 3n$A <br /> SIGN HERE �W ner ;�~ ,J •+ E �^n '" ? f <br /> a <br /> (a ture ofo6wner or building contractor) (date) c s <br /> ' 8 [ <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP P=MITSM�AYBER�EOUIRED��� <br /> r V55891! <br /> m <br /> 999989 to <br />