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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54672 Office of Zoning Administrator d - c a <br /> APPLICATION FOR - LAND USE - PERMITS3. <br /> 0 <br /> TO THE ZONING AD'AINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 N <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the a `m - <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and _ n <br /> regulations of the State of Wisconsin. H m <br /> R66 Dueek <br /> n F <br /> OWNER(Please Print) Contractor or Surveyor or Agent v <br /> Rt. #3 Box 240A m <br /> A dress Address <br /> Iveh FaUz, wI 54022 <br /> City, State,Zip Code City,State,Zip Code <br /> (715) 425-9924 <br /> Telephone Telephone i <br /> Emergency/Fire No. and Road Name <br /> Lot 5, <br /> Oak PaA Addition, Section T kN R14ll Town nDewey <br /> Legal Description (as Indicated on tax statement) <br /> � L7 <br /> Permit(s)Applied for: <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z 'o <br /> Accessory Building Sanitary X Privy Subdivision ° a <br /> Garage J <br /> Structure Use: Santtah (P�f'CA Alin (A oe(L rn/ T Abbch �� r <br /> (family home/cabin, garage, additi , etc.) g <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). a <br /> 2. Show the location of the well (W), septic tank (ST),and drainfield (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 It c <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m P H <br /> dated by the owner. ///��� C ° <br /> PLOT PLAN /y) l ��,/7/ �S`/CQ M a ] <br /> /tom/ <br /> SLE ATTACHED <br /> J <br /> o <br /> J <br /> - O <br /> Z <br /> M o c T m m a F 'run <br /> A. aa'� n0 a = a <br /> $ m < mCmo � 3 <br /> O J ,O <br /> OZ 0 m 1 <br /> f ] ?I N Zr <br /> - m <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- F 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- N m O <br /> lion 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 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 a <br /> 00 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m ^ m <br /> m as <br /> N N 8: <br /> SIGN HERE wade Ru bhotrn <br /> (signature of owner oPERMITS <br /> tra o (date) WD <br /> o s <br /> ZONING ADMINISTRATOR <br /> II '� n N § NNHT <br /> TOWNSHIMAY BE REQUIRED __._J� $ o o & m <br /> 88 888rn <br />