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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> a <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 the m c <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. y d <br /> m m <br /> G/9 Ru to Sc Ne, cK a ° <br /> OWNER (Ple ePrint) Contractor or Surveyor or Agent o m' <br /> ;4/1., ..u. Ci/ RCra Si. , 1 <br /> Address Address <br /> Af�)�/cU tii51S, S ``IOn / <br /> City,State,Zi o e City, State, Zip Code <br /> � 6 7s7D <br /> Telephone Telephone <br /> Q -7 �Y3 A f. A6 #2D <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n Q <br /> Permit(s)Applied for: 0 , <br /> Dwelling Addition Filling/Grading Camping Unit 6 � <br /> v <br /> 0. <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: S i A /,/o en C / C /a R <br /> (family home/cabin,garage, addition, etc.) <br /> 1A <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). a <br /> 2. Show the location of the well (W),septic tank (ST),and draintield (DF). 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 c <br /> measurement to the ordinary high water mark of lake,stream,or river. d a <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 0 <br /> PLOT PLA/ M t <br /> Sim /��s� r <br /> Q6 / GNF3c£ � c�a II <br /> , <br /> c <br /> (n <br /> 0 <br /> L) <br /> �Cr o <br /> o <br /> v <br /> N <br /> 5l'A1�5 <br /> Poll'& <br /> L /aK <br /> EE 9 <br /> f <br /> roc = mm $ nVm <br /> 00 0. <br /> P o, m ,z M <br /> P , T m: <br /> C <br /> 8 Qc ; C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- : o m o 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- "a « O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor; m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m g <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 °�, o <br /> access to the above described premises at any reasonable time for the purpose of inspection, m g m <br /> m 3 m <br /> m A a <br /> m : <br /> SIGN HERE K `� "�`'^'� _ / 7 / T <br /> (signature of own bui o tr tort (date) e <br /> ZONING ADMINISTRATOR g <br /> TOW SHIP PERMITS MAY BE REQUIRED &' N o o m <br /> $ $ 888888rmn <br />