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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator u m or o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and �2 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the o a <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0 �� <br /> regulations of the State of Wisconsin. w o <br /> f o <br /> a f <br /> 0 N�R Vasqu?pA r� Contractor or Surveyor or Agent o ? <br /> m <br /> m <br /> Adores Address <br /> 15-To Acj <br /> Ci State,Zi o e City,State,Zip Code <br /> i�-i V--93,a , <br /> Telephone ! 673 IyI�G7/ TwN RU� Telephone it <br /> Emergency/Fire No. and Road Na�QpIe <br /> L G fS <br /> /pd <br /> -1 // f"6SSZtIn s�R/CS <br /> Legal Description (as Indicated on tax statement) q <br /> ci; G, <br /> Permit(s)Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> gyp�� � � �r� r <br /> Structure Use: �^�:,� ;Sf��a- u(- l�7 �� Xyf� _ r <br /> U (family home/ca In, garage,addition, cl.et ) <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). 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 o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. <br /> C <br /> PLOT PLAN (a <br /> i 1 <br /> c 1� 0 <br /> E � <br /> N I J( <br /> O <br /> Q <br /> 70 <br /> m <br /> C <br /> i 1 <br /> j ot1U 7��f 11�;; <br /> 1 <br /> Ia �; <br /> I <br /> ' S NmvNr' DD' 23a0. <br /> m Da, 2-,n0 Aga <br /> < ` 4 c <br /> Z o ' m <br /> ti — — M <br /> m � : c <br /> 81 �\: € <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- �! ; Mm <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <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. t- Ev.. $ <br /> further accept all liability which maybe 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 described premises at any reasonable time for the purpose of inspection. m 3 $ <br /> N n <br /> SIGN HERE <br /> (sigp ur of owner uilding contractor) (date) o <br /> ZONING ADMINISTRATOR / $ <br /> 1 ° N <br /> TOWNSHIP ERMITS MAY BE REQUIRED o N ' NN Tm <br /> N ,Bi i% ,'o075 <br /> 6 � <br />