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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator M o a <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v 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 3 a <br /> regulations of the State of Wisconsin. d <br /> OWNER Plea. se Print) �3 S e CTornrador or Surveyor or Agar o <br /> (�7Tn <br /> lr 5L_ /� alit•—c /Li'r . m <br /> Address Addr J> —� <br /> City,State,Zip Code City,State, Zip C de (✓' <br /> Telephone Telephone � <br /> �i� - 93S - 3 7/ln �, ) <br /> Emergency/Fire No. and Road Name a <br /> 4. 54 a la e <br /> Legal Description (as indicated oh tax statement) T <br /> ct <br /> Permit(s)Applied for: 0 o <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit S <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° m rn <br /> Garage <br /> Structure Use: "a j <br /> ,7e F �„i L L�.o�.-��✓� _ <br /> famity home/cabin,garage, addltion,_gtq.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M — <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). Q o v, <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 1Az `v <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 A N <br /> dated by the owner. C Z <br /> PLOT PLAN 41111 <br /> S <br /> I m <br /> n <br /> O <br /> 7 <br /> o IVc <br /> - :_ <br /> WFC ,p�1Mi t <br /> pin \9 <br /> PP <br /> cwt" <br /> lIS D <br /> Z o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- _ H w D <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i�m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g 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 m^� b <br /> access to the above described premises at any reasonable time for the purpose of inspection. g <br /> m 3 <br /> m i v y w <br /> m : m <br /> N N 8 <br /> SIGN HERE <br /> (signa a owner os ilding contractor) (date) <br /> 8 <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP P MITS MAY BE REQUIRED a 08 008111 <br /> SEP - 81992 98999999y <br />