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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m 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 m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 r <br /> regulations of the State of Wisconsin. w m <br /> -72'0-c -fLl hda 6' JJe"pan a > <br /> OWNER(Plea rim Contractor or Surveyor or Agent o 'm <br /> XI15.3 � ,>•//sho�� 1�R. m <br /> Address I I-r Address <br /> bran <br /> City, State,Zip Code _ City, State,Zip Code 7J <br /> G <br /> Telephone Telephone r4 <br /> Emergency/Fire No. and Road Name 1 �` <br /> Legal Description (as Indicated on tax statement) <br /> c) <br /> 0 <br /> Permit(s)Applied for: r/ <br /> Dwelling Addition Filling/Grading Camping Unit ° o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° $ <br /> Garage <br /> Structure Use: ramal lei #dme o <br /> (fa ' home/cabin,garage,addition,etc.) <br /> 1A <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 o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). '1111 -63 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 q - c <br /> measurement to the ordinary high water mark of lake,stream,or river. P 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. C °_ <br /> PLOT PLAN �J / m <br /> I <br /> 0 <br /> L �S)�l/ 7� fr/��W N <br /> I <br /> fvufcw 7s ' ge r T° m <br /> Ca�C� /3 <br /> mo � � dmDg7m <br /> m. D�� maH a = a <br /> Z o m ,z M <br /> oma , m <br /> C <br /> 8 ' i mm rn <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 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 n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. ((''`` v $$py N <br /> SIGN HER H n <br /> (signature of owner o uitd' g con r) (date) <br /> ZONING ADMINISTRATOR loll <br /> Pi 0 . <br /> TOWN HIP PERMITS MAY BE REQUIRED <br /> P0 . <br /> 888898 8 <br />