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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m a . <br /> f <br /> APPLICATION FOR — LAND USE — PERMITS 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <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. m m <br /> -7%// CSV � m <br /> n&&-< or rre- cc <br /> f <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> — C <br /> m <br /> Address.. Address <br /> I� ear �(kP Wrf 551/0 <br /> City, State,Zip Code City,State,Zip Code <br /> /- 61a- ,lag - D33 , <br /> Telephone Telephone <br /> a9 6S �onQ 4cl.fit' —rm;L Oa ti 6urL.( <br /> Emer eney/ I e No. n Road Na <br /> s.3� �f�� V& W >�C/ /6Low -� csrrl V 7 P iii <br /> Legal D— eption as Indicated on tax statement) /N oIV Lot ,3`E br/ng The 0 doo'- f"C4 <br /> 6, 050 f}creS O <br /> Permit(s) Applied for: o °. <br /> J <br /> Dwelling X Addition Filling/Grading Camping Unit S <br /> c <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: o <br /> (fatuity home/cabin,garage, addition, etc.) <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). <br /> 2. Show the location of the well (W),septic tank (ST),and dralMieid (OF). 3 w <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 c <br /> measurement to the ordinary high water mark of lake,stream, or river. o o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and U H <br /> dated by the owner. M <br /> PLOT PLAN <br /> 1-/ltltuu heel C¢uvC�1 ilt�y' m t}� <br /> d�y� 6i1,� ��/G.kllfZ"Ce�R<<c,�j" l� l�e';' f✓�' <br /> /p,ned�SC'��CC YCl2ia/P,n v.a�j r �� <br /> e <br /> 1 m <br /> v O <br /> J <br /> N <br /> v q� <br /> OJ <br /> < ke to 1,cj V+ 9�/ <br /> `r • <br /> E 1 Z <br /> V VO aB N ❑` � <br /> '� DF <br /> 6sy , 4y - <br /> �l � ro 3a. a � ,---♦ <br /> � o0, � dmag9 <br /> m <br /> A f ! E y? E M <br /> = m <br /> c <br /> ? m� : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o a� �: 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- N m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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- M <br /> plication.1 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 purprT of inspection. m g <br /> SIGN HERE _ 5et 79L ' w t w <br /> (sig ure of owner or buil tor) (date) c x S <br /> ZONING ADMINISTRATOR 0 g ' <br /> SE 6 '= <br /> TOWN HIP PERMITS MAY BE REWIRED <br /> `���� ✓ ' 998888 <br />