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6) ) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m ; 0 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 m r <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m _ <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. H m <br /> MMU Lo L .r-Sct,-A L scA a <br /> 0 NER (PI ase Print) Contractor or Surveyor or Agent o `� m' <br /> 6Lnl'TA16 Ave. nlei <br /> dress Address <br /> IV*L 1Ft f 55V4-3 <br /> City, tate,ZiP Code City,State,Zip Code <br /> Telephone Telephone - <br /> Emergency/Fire No. and Road Name e <br /> Legal Description (as Indicated on tax statement) r <br /> m � <br /> Permit(s)Applied for: 0 s <br /> w r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage II I 0 n <br /> Structure Use: 5 -' O rQ j V_ Q�(]G e h 4 ) GJI Ci/LCGL r <br /> (famil ome/cabin,garage, addition, etc.) <br /> 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). o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 a v, <br /> 3. Show dimensions infeet ofthefollowing:(a)building to all lot lines,(b)buildingto center line of road,(c)building .q Z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and M <br /> dated by the owner. C 0 <br /> PLOT PLAN <br /> J <br /> 6 <br /> m <br /> I� <br /> o <br /> N r/-1 <br /> I n I� <br /> --- ) Z <br /> s <br /> 5 ( <br /> 1 <br /> �a <br /> > > � a m <br /> \ D a m n u N D <br /> 0 <br /> o o ` <br /> Ems : cN RDI <br /> (J» O <br /> 8 m <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.1 acknowledge that I am responsible for the detail and accuracy of all informa- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g m 8 <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 /> OPO <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 o , <br /> A rt A m <br /> SIGN HERE '� ^� T N <br /> (si at e f wn ullding ntractor) - .(date) <br /> 'NG ADMINISTRATOR g <br /> N NONHN (M/ T <br /> TOWNSHIP PERMITS MAY BE REQUIRED rn rn m an o o m <br /> JUN - 4 1992 s99898880 <br />