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..i / �. %) )4) <br /> Burnett-Cqunty 7410.Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ' z <br /> m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <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 N <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. m =' <br /> m <br /> C O <br /> n E <br /> OWNER (Please Print Contractor or SSurvEgyc)C & m <br /> YY�I�I NATION <br /> Address Address , X <br /> 1'.0 . 1�J-A (e`'f 4 GY1Py... �ff CAIIAI _ <br /> City, State,Zip Code City, State,Zip Co-&e(71535,7482 <br /> �redtrt0LI y) . <br /> 54 $3 7 M�" <br /> Telephone1 Telephone <br /> fe3S 7_09q C�"d_ <br /> Emergency/Fire No. and Road Name <br /> 0 <br /> Legal Description (as indicated on tax statement) - <br /> 0 <br /> 0 <br /> Permit(s)Applied for: ° ^- <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Z o <br /> Accessory Building Sanitary _)e _ Privy Subdivision P <br /> Garage <br /> Structure Use: - 4 <br /> (family home/cabin,garag , addition,etc.) <br /> IDIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M O <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfleld (DF). 3 <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building toceMerline ofroad,(c)building � Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. ° n I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o rn <br /> dated by the owner. C <br /> a <br /> PLOT PLAN III t V <br /> l +lyi <br /> N <br /> m <br /> r <br /> O <br /> I, <br /> Iti <br /> O y <br /> 2 <br /> D o c �_ m v n n f m <br /> m <br /> " m o 0. 03 <br /> $ <br /> Z Ems : T2 . M <br /> m <br /> i 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- om <br /> edge and belief it is true,correct and complete.I acknowledge that am responsible for the detail and accuracy of all informs- w N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8� 8 <br /> mation 1 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- <br /> plication. I agree to permit count officials charged with administering county ordinances or other authorized person to have O u, o <br /> m 8 m . <br /> access tot a above described mises at any reasonable time for the purpose of inspection. m A N <br /> a a � <br /> Io- 1O -`jZ <br /> m : <br /> o : <br /> SIGN HERE (date) <br /> signature o wner or buildip co ract ? ` <br /> /�r C�Z <br /> ZONING ADMINISTRATORy,(yy(��,, {{��,, <br /> N N N N O O O m <br /> TOWNSHIP PE ITS MAY BE REQUIRED $8 8 $ 8 8 $ v <br />