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d) Q ,���:> <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; 'D -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> 0 <br /> TO THE ZONING,ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and R <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 'V m <br /> Burnett Cbunty 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. w m <br /> J910 f ID Vt-T=ots o S(= Z_ '{ = o <br /> a f <br /> OWNER (Please P int Contractor or Surveyor or Agent o <br /> CJf( �` d N" ` / 2 <br /> Ydress Address 1 <br /> ( Loom 10 7-00 (3V_ <br /> City,State,Zip Code City,State,Zip Code <br /> q cir d '�_' r <-- <br /> Telephone Telephone — <br /> _D'7GRy FRk-Ir D <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permits)Applied for: o <br /> J <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit 6 ° <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage /1 R AA nn / <br /> Structure Use: `� A 4 o F <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (Vi),septic tank (ST), and drelnflaid (DF). 1111 3 va <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 11 Z `o <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m N <br /> dated by the owner. <br /> PLOT PLAN m <br /> See Adafi- Pd bre;' <br /> 0) <br /> 0 <br /> 1r1r11J <br /> N I'V <br /> O II�1 <br /> J <br /> J <br /> O � <br /> y <br /> I <br /> Z <br /> A o c � m m o n ? m <br /> Dg,* maN } Ax <br /> o Z <br /> mi M <br /> O <br /> C <br /> g ` mA : € <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 informa- <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. 1 8 m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have c, <br /> mm <br /> access to the above ibed premi s any reasonable time for the purpose of inspection. g <br /> ' 0 ^ <br /> SIGN HERE d' .9 i <br /> (signature of owner or building contractor) (date) o s i <br /> ZONING ADMINISTRATOR <br /> N <br /> TOWNSHIP PERMITS MAY BE REQUIRED !n 3�u o o m <br /> 88888888rma <br />