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C%� <br /> bumett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v 'a 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> I ° <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v a Ute! <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. <br /> ' /ira m <br /> RLtS F• OR.h?I �r®N � L`.t'F l�p �/� �G.L �k'/ �1�1� n �f <br /> OWITER-Please Prin Contractor or Surveyor or Agent o m' <br /> 2'i4 � YNnI ':ATI <br /> Address Address <br /> si &I L4 tet, 5�, �, I ► Yw Qp wI, <br /> City, state,zip cod I Z t q,�u Sr city, state,zip code <br /> QA <br /> Telephone Telephone <br /> nerM q f4eAtrE d/ CN r?0RD <br /> Emergency/Fire No.and Road Name If V <br /> Legal Description (as Indicated on tax statement) -� <br /> G) <br /> Permit(s)Applied for: ° <br /> 3- _ - <br /> Dwelling V Addition Filling/Grading Camping Unit o 4 <br /> t <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage �I r <br /> Structure Use: <br /> (family home/cabin,garage,addition, et .) 4 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) n y <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 7' <br /> 2. Show the location of the well (yi),septic tank(ST),and drainfleld (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 c <br /> measurement to the ordinary high water mark of lake,stream,or river. ° o <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and w. <br /> dated by the owner. C dX <br /> PLOT PLAN r N0 1 S,yrf <br /> D Y <br /> O Lit C) <br /> .a a 0 U <br /> W � <br /> m <br /> Pe Acyr !A o <br /> C <br /> ^ I <br /> Df rc J Z <br /> o0m > > oaF m <br /> n a <br /> _._. <br /> �. m ' ZuCio �m 3 <br /> o . r� M <br /> M <br /> S c - : [ m <br /> C <br /> m'm M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o : E m <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- c I yy++ [ O <br /> tion contained in this application(Including any accompanying schedule)and I further declare that 1 recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issugipermit. 1 8 m 8 <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> B $ ^ a <br /> SIGN HERE <br /> (signature of o ner r buil contractor) ate i <br /> c : s: <br /> ZONING ADMINISTRATORAUb <br /> j F <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> IuU� - 888888 8y <br />