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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o a <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 � c <br /> Cc <br /> 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 3 0. <br /> regulations of the State of Wisconsin. y <br /> N � <br /> C <br /> n £ <br /> OWNER,.(Please Print) Contractor or Surveyor VA8eK o <br /> ,:,(Please <br /> CD <br /> Address 4W4 -10 Address HM 59, 00 47 <br /> 8 <br /> City,State,Zip Code Cry, State,Zi ar,, W1��n <br /> 'So an new . u�� J`I'$0) 2• 482 t <br /> Teleph ne r� _ aibl Telephone <br /> -IIS - VE!Eb- <br /> Emergency/Fire No. and Road Name <br /> S <br /> Legal Description (as Indicated on tax statement) o <br /> cf <br /> Permit(s)Applied for: o °- <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit 6 °- <br /> v <br /> z o <br /> Accessory Building Sanitary - Privy Subdivision ° <br /> Garage <br /> Structure Use: _ <br /> famih bin, garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 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 drainfield (DF). 3 <br /> 11 0 <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 m <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 y y� <br /> dated by the owner. ; 1„ <br /> C ' <br /> PLOT PLAN , <br /> m <br /> l <br /> Ars ANi Ac%A4A <br /> 0 <br /> o <br /> N Iryx,11 <br /> ~ � I <br /> Z <br /> m m n n m <br /> ams <br /> < as : H o > > 3 <br /> z mo A .z 2o E T N M <br /> O O <br /> g m rt S <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- w m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- �" 'm N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 I 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 /> 6 A N A <br /> SIGN HERE <br /> (signidure of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR 8 <br /> ;i MAY I g ,i 889 MW <br /> TOWNSHIP PERMITS MAYBE REQUIREDI 1) 1 j & o o 9 m <br /> 8 ( 888 N <br />