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On (!;o ) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren,WI 54872 Office of Zoning Administrator 'a f c <br /> APPLICATION FOR — LAND USE — PERMITS o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 v <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 <br /> regulations of the Stale of Wisconsin. <br /> IIJOrIVI�Xw-I- L J /-4— a f <br /> OWNER(Please Print) Contractor or Surveyor or Agent m r) m <br /> I x{38 5� Kms <br /> Address I 1 Address c� <br /> 6 Q 5y r Spao e. UIIS SIM6 / TI <br /> City,State,Zip Code City,State,Zip Code W <br /> TelephTelephone <br /> one <br /> 3 {( � <br /> Emergency/Fire No.and Road Name —1 <br /> (D <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> O <br /> ^_ <br /> PermitO <br /> Ts) Applied for: TA <br /> w r <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit °� I <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision P } <br /> Structure Use: <br /> (family home/cabin,garage,addition,etc.) <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). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 <br /> 3. Show dimensions Infect of the following:(a)building to all lot lines,(b)building to center line of road,(c)building -q c S <br /> measurement to the ordinary high water mark of lake,stream,or river. I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and ; a <br /> dated by the owner. <br /> / pC <br /> PLOT PLAN `'7aJLeUe ,$ <br /> I <br /> t4'u 8bd5- <br /> T <br /> lJ `� <br /> 0 <br /> 0 <br /> 2. Q <br /> c � <br /> w <br /> r Z <br /> 9 <br /> ( <br /> See <br /> i! <br /> 0 o c Q F T <br /> = FL oaf = M <br /> c -<. eco 0m' 3 <br /> oZ . re � � 1 <br /> ' vi m <br /> � � . <br /> At <br /> 8 i W ' a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c ? ; 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- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this in or 8 vt <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I P . <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 spree to permit county officials charged with administering county ordinances or other authorized person to have g <br /> access to the above described premises at any reasonable time for the purpose of Inspection. 8 g <br /> B 8 " ° ' <br /> SIGN HERE <br /> (signat a of wner or bu 1 1 c tractor) (date) o <br /> 8 € <br /> ZONING ADMINISTRATOR <br /> To <br /> PERMITS MAY BE REOUIRED <br /> 888888 $ 8rmn <br />