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rJ� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office Ot Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> m c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 ,� <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and _ <br /> regulations of the State of Wisconsin. � �1 w m <br /> TE Ray CH✓ANaJbM Ale iiarL n o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> 13 1 1 aoc K I AVE- R6 ° ri <br /> m <br /> Address Address <br /> SPdoni ER 5480 <br /> City,State,Zip Code City,State,Zip Code <br /> �/ - 635— "89 r <br /> Telephone Telephone V1 � <br /> i39�✓ Doclf CFI✓CE- Rd. <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) Ll <br /> 3 O QPermit(s) Applied for: 0 t. <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> 1 <br /> z <br /> a <br /> Accessory Building — Sanitary Privy Subdivision o r` <br /> Garage p n <br /> Structure Use: G-j9R A 6- F_ 30 �� r <br /> O <br /> (family home/cabin, garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 2 <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 (N),septic tank (ST), and drainfield (DF). 3 u, <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)buildingj Z `v <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m N <br /> dated by the owner. n C <br /> PLOT PLAN <br /> rc <br /> cn <br /> o <br /> L <br /> o <br /> ISV <br /> m <br /> n <br /> 30. me `0i � y <br /> a< . me » o' 53 <br /> 0 <br /> c m <br /> rn : 4) n O <br /> m c C <br /> a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 : m [ m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- zNk <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 (f) 8 m 8 <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 <br /> i " � ,' <br /> SIGN HERE <br /> (signature of owner or buil#19 contractor) (date) <br /> ZONING ADMINISTRATORJ,X11 k- AA1,60k) <br /> TOWNSHIP PERMITS MAY BE REOUIRED o o«d m <br /> 8999999 <br />