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i/ � (6(;V-) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 'U c c <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 m c <br /> located 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 n 1 i <br /> regulations of the State of/niscon ' H m° <br /> f�lLl�Flt2g V 0�L,()N Fo 2-koo- k L�-�tmPEe 5 a " O <br /> OWN R (Please riot)� q Contractor or Surveyor o o _ ' <br /> q // �Agent <br /> )Z W ooO✓i lsw � 044 X loo L Fpoy-r J T KEET <br /> m i � <br /> AA-E1 , 1-7- .5-3 Oq Z A-dpY OnIF_,e? /,HJT Sal 0! t \' <br /> E(�uloN (/V1 <br /> C'y Stat ,Zip de City Stat Zip Code <br /> - <br /> )y yz <br /> Z -031 ( '7151 635- 871q <br /> Tpffeprione Telephone <br /> Rc No 14( Inl. Loose <br /> LaK� <br /> Emergency/Fire No. an Rol a e <br /> L0 z. GSJVJ �o P 17( (znl Goy Lo 1 <br /> Legal Description (as Indicated on tax statement) o —j <br /> n/� <br /> � cf <br /> Permits)Applied for: oE� Rj-r #e9MEN7- 0 <br /> Dwelling Addition Filling/Grading Camping Unit 0 ° <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision q � <br /> Garage <br /> Structure Use: <br /> C A-&AI <br /> (family home/cabin, garage,addition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfieid (DF). 3 m <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road, (c)building 1Az `v <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 H <br /> dated by the owner. C 7- <br /> r- <br /> PLOT PLAN _� <br /> /Vote_ 0 his fe/rit,t-O_orlYc-�5 /VU� aolmfd+vs Nd6i=,Q o^� -f5,gI . M = <br /> `1� Na .e("j0k� �7i.7wS L.,If bt. F,K'l.}we� Un�IGSS UFG� —i�c'.=i5 .�"Bec� a f' <br /> -rb Lo4- (_1..e'- S0+ %i. in <br /> 0 <br /> 19 <br /> / I 1I`ILo� <br /> / V V O <br /> O � <br /> x, <br /> /y <br /> f1� V oa <br /> _ Q R,� Kam <br /> SCG UW�w �n �K� a A<� QH oo on 3 <br /> o � s = rn[ m <br /> 0 <br /> 8 ' € A m s <br /> I declare that this application(including any accompanying sch I has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowled I am responsible for the detail and accuracy of all informs- � '' N m O <br /> tion contained in this application(including any accompanyin chedule)and I further declare that I recognize that this infor- ro v, <br /> mation I am providing will be relied upon by the County o urnetl Wisconsin in determining whether to issue a permit. I g m $ <br /> further accept all liability which may be a result of the Cc ty of Burnett relying on this information I am providing in this ap- N <br /> plication. I agree to permit county officials charged with ministering county ordinances or other authorized person to haveu <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> m n a <br /> SIGN HERE <br /> (s' Kat a of owner r ilding contractor) <br /> ZONING ADMINISTRATORS—� ^,`L � <br /> / v ' Igg . NNNNN � <br /> TOWNSHIP PERMITS MAY BE REOUIRED 9 "n X N X o 0 1S m <br /> 88888888umi <br /> I <br /> , <br />