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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m a <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of/the State of Wisconsin. y m <br /> RLr.K / S" SPITT.E7.L M02LE t15SuCUSTOM CA'R/TENT 2'-1 n <br /> OWNER(PI ase Prim) Contractor rveyor or m o <br /> 1 E I PK w 7-SI-14-1 }}uw 3 S <br /> Address Address <br /> Rot`.4;ci - -t2 11A 1) SS9OZ uas6STg2 LjT . 54893 11 <br /> City, State,Zip Coder City, State,Zip Code <br /> 1-so-1 - $Z- (o 810 1&G__ 8f81 <br /> JJ <br /> Telephone LTelephone <br /> Emergency/Fire No. and Road Name <br /> Se-r- a (0 r -ryoN•R,sw -- <br /> Legal Description (as Indicated on tax statement) <br /> n O <br /> Permit(s)Applied for: 0 °. <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Building X Sanitary Privy Subdivision ° <br /> Garage <br /> f/ <br /> Structure Use: IAZE(�p SERSOIVgr_ W� OECK. -� _ r <br /> (family home/cabin, garage,addition, etc I o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 <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 o <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 y <br /> dated by the owner. C <br /> 1 <br /> PLOT PLAN <br /> -> —� + )1010 <br /> Z <br /> f ScOE <br /> o <br /> oa P <br /> Pt <br /> U mmv ry, r DDO 9 <br /> vamamamy <br /> < 3 « o O 3 T <br /> i <br /> fes : ni x <br /> � 2 o <br /> c <br /> 0 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- yy!! m: O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 75 o P <br /> mation I am providing will be relied upon by the County of Burnell Wisconsin in determining whether to issue a permit. I g m 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 Ou+ o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 0 80 <br /> m v a ? <br /> P <br /> (! W N <br /> SIGN HERE s <br /> (sign of owner orb 'Id' 9 contractor) _ datf�,�)i�77", <br /> r ' I , <br /> ZONING ADMINISTRATOR <br /> kNTOWNSHIP PERMITS MAY BE REQUIRED o 8 m <br /> APR 2suPss88son88 <br />