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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d 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 m i <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations hof tthhe�State of Wisconsin. may' H °_ <br /> IFIL (�3M_�.ShlE►2 TAmEs 14, PES a m F <br /> OWNERPlease PnrritP)T' / Comraaor or Surveyor or Agem o <br /> �E <br /> ccaL 111J�C1/ m .J <br /> m <br /> 71 <br /> A57" PA1IL �/ & Add <br /> onapwRY . w(sc -Y336 <br /> City, State,Zip Code City, State,Zip Coe <br /> Telephone Telephone I — <br /> 6/oZ- 777- .?737 / / y \ <br /> Emergency/Fire No. and Road Name VIE.T, VA p �,�N� l 6V/ K1 <br /> Legal Description (as indicated on tax statement) �' ))A R <br /> n L7 <br /> Permit(s) Applied for: o 0 <br /> Dwelling Addition Filling/Grading Camping Unit o °– <br /> v <br /> 2 0 <br /> Accessory Building Sanitary Privy _ Subdivision <br /> Garage <br /> Structure Use: Pf (V y <br /> r <br /> f (family home/cabin, garage,addition, etc.) o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <br /> 0 <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 dralnfield (DF). 3 <br /> 3. Show dimensions Infeet of thefollowing:(a) buildingto all lot lines,(b)buildingto 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 H <br /> dated by the owner. <br /> C <br /> PLOT PLAN m <br /> Z <br /> IJJ <br /> l�aCjq <br /> tf� <br /> V N <br /> J o <br /> O <br /> m <br /> O y <br /> m <br /> f. iv ItJ <br /> Z <br /> ADD <br /> 2 y <br /> oc � naF m <br /> m, yn� '— 'aNnm <br /> F M T� <br /> € m <br /> mom : c: <br /> 8 A A € x <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S : 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- 00 O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor `�' <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 T 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g m <br /> m 3 0 . <br /> N A <br /> I c-7 -9/ <br /> SIGN MERE H H a :: <br /> (signature of owner or building contractor) (date) � � <br /> o : x: <br /> ZONING ADINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED L"G ��o o m <br /> 88888 $ $ 8ai <br />