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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; 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 H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. H a <br /> N V <br /> �q�-t tT �rnPc/ mAt� n o <br /> OWNER(Please Prim) Contractor or Surveyor or Agent m m <br /> 709/ R .w., vv <br /> Addr ss / Address 0— <br /> C�ghk �J�i nn. rJ-1317 <br /> City, State,Zip Code City,State,Zip Code <br /> 4/z- 'Y7,V- 3-G�/ <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name , <br /> Legal Description (as indicated on tax statement) o <br /> n <br /> Permit(s)Applied for: 0 °- <br /> ` { w r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: m 0 Trill,I e-r <br /> �(fami ome/cabin,garage, addition,etc.) all! o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <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 (W),septic tank(ST),and dralntleld (DF). 3 <br /> 3. Show dimensions Incest of the following:(a)building to all lot lines,(b)building to center line of road,(c)building11 if Z a <br /> measurement to the ordinary high water mark of lake,stream, or river. o v <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 0 w <br /> dated by the owner. <br /> C � <br /> PLOT PLANN M q} f <br /> a <br /> Coo <br /> Lmf G,^nom fi <br /> 1 <br /> � c <br /> i' o <br /> ID <br /> � o <br /> E <br /> T y 5`id <br /> Z <br /> fi — v <br /> , oQ <br /> Ao c � m m A, a F2. n91 <br /> A _ P < ' > tf p <br /> iF 33 <br /> o. <br /> z `@. H .20 oo 3 ,o' 3 <br /> O Y T N <br /> cc : In <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g , 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i$ro N <br /> matfon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 w 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 n N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m . 3 8 m <br /> n <br /> SIGN HERE <br /> q M <br /> (signature of o ner or bulr t 0 c x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP ERMITS MAY BE REQUIRED��1 _ 8r�t7n aN8� 0 0 0 9 M <br /> 888 $8gmo <br />