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�3Y�C�r 0 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,N m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3' <br /> w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v <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 3 <br /> regulations of the State of <br /> Wisconsin.y� / _ (' <br /> L7 i L.L S T. V C V 566 n 7c- F <br /> OWTR(Please Prim) Contractor or Surveyor or Agent o <br /> � 5 SK.�✓IE('k. L-KI W � <br /> Addr Address <br /> City, State,Zi C e 2 CD�l SJ aT� Cry, State,Zip Code J <br /> mid -� h _ <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> � O <br /> Permit(s) Applied for: �X! 0 �. <br /> Dwelling Addition Filling/Grading Camping Unit o °- <br /> v <br /> z o <br /> Accessory Building SanitaryPrivy Subdivision P Po <br /> Garage <br /> Structure Use: o' <br /> 0 <br /> (family home/cabin,garage, addition, <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 (N). O oo' <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). v m <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 n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m n- <br /> dated by the owner. C U ; <br /> PLOT PLAN m <br /> la+ <br /> Uri <br /> �9 <br /> &KO <br /> 71,13 <br /> 0 <br /> 0 <br /> t6 , <br /> // V1 -i <br /> Z <br /> = r <br /> J n N <br /> "< ` : m o 5 m 3 <br /> o (Qo `° ,2 <br /> 2J TNi 3 <br /> m c <br /> gm m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o rl <br /> n <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- _ .n m w C <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. i 'm N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 � $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 n�' o <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN MERE t> -22 <br /> (signature of owner r IldIn - ('n? F'_ 8 s <br /> ZONING ADMINISTRATOR $ ' <br /> TOWNS IP PERMITS MAY BE REQUIRED 2 3 u,i o <br /> i <br /> 9 899 r <br />