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Cn v� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratora a <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <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 <br /> N <br /> f nw A �+3iNc�Z < G r l2/20�f r c o <br /> OWNER (Please Print) Contractor or Surveyor or Agent o ', <br /> L �a) � (/� <br /> Address ! % �� Address I �" <br /> City, Stati1Code �5!l y City, State,Zip Code <br /> p(f t U <br /> Telephone Telephone <br /> �/2 - '72- V9J�' <br /> Emergency/Fire No. and Road Name 6-75? 'M;N r�U✓� <br /> Legal Description (as Indicated on tax statement) (C}) a <br /> Permit(s)Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage, addition, etc.) o <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <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 architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. <br /> C <br /> PLOT PLAN m <br /> �f•/ .��; coq'-o ' • >� <br /> ?i fry r <br /> d <br /> �r 20 <br /> RAN <br /> m <br /> o <br /> Doi <br /> ;24".A34; a © r, <br /> 14 i <br /> am <br /> ,3�i'Jr ©rx Gu'T STACF �N: Amo 0. 103 <br /> f T� M <br /> n m <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my owl- 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 informa- m m <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 <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 u, <br /> access to the above tles pr mises at any r onable fine f r the purpose of inspection. 3 <br /> V n <br /> m <br /> - N <br /> SIGN HERE <br /> (signature of owner or i(ng contractor) da. <br /> ZONING ADMINISTRATOR ) g : <br /> TOWNSHIP PERMITS MAY BJKREOUIRED u VN 0 o o$ m <br /> JUN - 21�392 1988888880 <br />