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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS ' <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 theCD <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 Wisconsin. w m <br /> 0 <br /> OW ER (Please Print) Contractor or Surveyor or Agent o <br /> 34f7 Df4-y s -DKd U L C-� <br /> Ad res Address <br /> City,State,Zip Code City,State,Zip Code <br /> r7rs- <br /> Telephone Telephone <br /> 2347 Telephone <br /> Z7 DP"10, - <br /> Emergency/Fire No. and Road Name <br /> µgmQr EZb-�7 V39i 7�G 52L�T 9 ��I6 IrJlIv44 2,Soo PCL�39 [6.26 1n7Go !� <br /> Legal 15escription (as Indicated on tax statement) LOT I C-" v I F 163 PC L- DES V37P P331 <br /> (la/ Al#V SII o <br /> Permit(s)Applied for: 0 ^- <br /> Dwelling Addition —4- Filling/Grading Camping Unit <br /> v <br /> Z a <br /> Acco Buildin Sanitary Privy Subdivision ° m t <br /> Ta-rage <br /> Structure Use: o <br /> (family home/cabin,garage,addition, etc.) <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). <br /> 2. Show the location of the well (W),septic tank (ST),and dralnfleid (DF). an 0 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 <br /> measurement to the ordinary high water mark of lake,stream,or river. o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and — m <br /> dated by the owner. C 1 <br /> PLOT PLAN <br /> r- 4-A&2 <br /> o w <br /> ry <br /> •tea o (lsf^ Z <br /> \ Q�Fnx c <br /> V <br /> ,` ( m oc �mw $ osgv <br /> ills ��LI m ' z 0005* m <br /> D aaNa a <br /> Z . H —% . i <br /> T <br /> M <br /> i � � m <br /> mc , c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- g 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- «m >, O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E }o m <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. Ii <br /> S 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 <br /> access to the above ascribed premises at any reasonable time for the purpose of inspection. m 3 $ <br /> A A H <br /> fAll <br /> SIGN MERE <br /> jillignature of owner uil i g c t a c s <br /> ZONING ADMINISTRATOR qq$ <br /> TOWN HIP PERMITS MAY BE REQUIRED SEP 2 5 10 00 8 0 o 0 8 m <br /> 8888888y <br />