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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) m a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> 1 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <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. H m <br /> Ci a1- IeC L kG <br /> Q_ n o <br /> OWNEpi( leasBee Print) ' / Contractor or Surveyor or Agent o - <br /> / �� O r o � �S 7- H UASd <br /> Address Address <br /> City, State,Zip Code City, State,Zip Code <br /> Telephone Telephone C\ <br /> ��. BA�s Lr4k aj <br /> Emergency/Fire o. and Road Name <br /> 1_0�3 L°-S/rl 1/0/"3 Oa 115 <br /> Legal Description (as Indicated on tax stateniedt)O c # <br /> cls. <br /> Permits)Applied for: y It. <br /> Dwelling Addition Filling/Grading Camping Unit o = <br /> Accessory Building Sanitary Privy Subdivision P 0 <br /> arm age p q <br /> Structure Use: L I U(ry!5 4n2.4 /�trLl vTjav fN ad e- � SUS fa <br /> (fatuity home/cabin, garage,addition,etc.) � <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 J� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). M <br /> 2. Show the location of the well (W),septic tank (ST),and dralydield (DF). 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 '11Z o <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 f7 y <br /> ated by the owner. M o <br /> PL T PLAN M <br /> m <br /> I n <br /> III G� <br /> O � <br /> oe <br /> (r� G <br /> ay <br /> CY <br /> Z <br /> o c m m n n g m <br /> =m —�� � am ams <br /> 7/09 - orf N o m <br /> to rn/Yt -I' P * 3 ! cy m <br /> /y0 �i�sc /4i+r�/ti2 ct » O <br /> 7� g ; <br /> I declare that this application(including a 7 <br /> accompanying schedule)has been b�kar ined by me and to the best of my knowl- o_ ` p m a <br /> edge and belief It is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- a m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I 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 g 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 described premises at any reasonable time for the purpose of inspection. m 3 8 8 <br /> ^ m <br /> m <br /> SIGN HERE <br /> (sig u of owner or I Ing contractor) (date) <br /> c : s : <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PER ITS MAY BE REQUIRED N g c,c 9 m <br /> 88888888fmn <br />