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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 - a <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 m <br /> Burnett County 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. �, m <br /> UIBYtrl-MAOW 0)0 <br /> OWNER (Please Pr' ) � Contractor or Surveyor or Agent o <br /> 3 go( ' 075 a '4 A <br /> Addre s v <br /> Address 1 <br /> rAat,s rrl r A,fv s— ra 171 <br /> City, Stafe, Zip CodeCity,State,Zip Code j CD <br /> to/'�;j `tom/ - Y3/`7 t <br /> Telephone Telephone 4- <br /> Emergency/Fire No. and Road Name <br /> Lof !/rl� L-s'/C Y Lake 17cke&'Z;e L�nct�yt Jc <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> Permit(s)Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> Z v <br /> o <br /> Accessory Building x Sanitary Privy Subdivision ° <br /> Garage Ct' <br /> Structure Use: ���� 1 r r A 1 {�l 0 <br /> (family home/cabin, garage, 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). o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 v <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building Z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m w. <br /> dated by the owner. C K <br /> PLOT PLAN <br /> I <br /> see led <br /> v <br /> co <br /> O <br /> O <br /> O <br /> IC <br /> I Z <br /> S <br /> N o c -Dmm � n � 9 <br /> 0. Da` 'anw a S. M <br /> o o , m .z ; M <br /> m <br /> [ � c o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- r� o m m 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- d.m N O <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ro N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 a 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing mthis ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 00 O <br /> access to the above described premises at any reasonable time for the purpose of inspection. m-o 8 m <br /> w <br /> SIGN HERE <br /> (sign of owner or building contractor) (date) x <br /> �r o : <br /> ZONING ADMINISTRATOR <br /> M. <br /> �-/TOWNSHIP PERMITS MAY BE REQUIRED u,0 r8 .0 o o� 'n <br /> 88888888na <br />