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-.rI C- YY)J <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 /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <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 State of Wisconsin. m m j <br /> E d <br /> OWNER Please Print) , Contractor or Surveyor or Agent v <br /> 5`i a Priv" s t_r\ice Ra <br /> Address Address IZ"\ <br /> V.�a\oSt <br /> City,State,Zip Code City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) A <br /> n L) p <br /> Permit(s)Applied for: V- <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: req �� o <br /> (family home/cabin, arage,addition,etc.) <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). n <br /> 2. Show the location of the well (W),septic tank (ST),and dralydield (DF). 3 <br /> 3111 <br /> . Show dimensions Infest of thefollowing:(a)buliclingto all lot lines,(b)buildingto center line of road,(c)building z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o a I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and n• IIy��J,\' <br /> dated by the owner. <br /> QFoQ LINe C I <br /> PLOT PLAN YT) wr9- 011p o'o% VCt A- ) zt" III <br /> z \ <br /> / o <br /> f <br /> U,. <br /> f m 1 <br /> 9 )2 o <br /> �. <br /> See Ped,let t <br /> 1�6 <br /> Tae `MrC 1�b'3 <br /> �dd�tieN <br /> ON Via St I <br /> 2 to V U 0 U) co 0, n F T <br /> M. gr >'1u a = M <br /> ° A <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- 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- w a O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 818 N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 ': 8 . <br /> 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. ' m g <br /> m v A e <br /> m m <br /> M N <br /> SIGN HEREki <br /> (si atu of owne wilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIRED t N o o's m <br /> $ 8888888rmn <br />