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C 'a Y r <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - �/ o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> a � <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Z <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 <br /> re�g}ulations of the State of Wisconsin. �, m <br /> n l>r,.,� F� N e L 54P L F <br /> of <br /> 0 N R�((Please Prim) Contractor or Surveyor or Agent o - <br /> 3(o CO _Cornl.�J )9b' in Grocrs� s .cJcv, m <br /> Address, <br /> Address1 <br /> c�1 e its+Fr w;s c. x{893 cc-evj Rr32,1 MAI SW4I 3 p - <br /> city,Stoma e Zip Code City, State,Zip C de <br /> Telephone Telephone <br /> 83 ��.3 GovCs,Vctn1 <br /> Emergency/Fire No. and Road Name �y <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> Permit(s) Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit <br /> _ ' <br /> Accessory Building Sanitary Privy Subdivision ° W <br /> } <br /> Garage <br /> Structure Use: / o <br /> (family home/cabin, garage,addition, etc.) <br /> 1A 9� <br /> 0 -� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <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 dralnfleld (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 v <br /> measurement to the ordinary high water mark of lake,stream,or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. C <br /> PLOT PLAN 4-ai m 9 <br /> N <br /> I Ca�niN J o <br /> F .y. <br /> J IUI I � n fJ'a/ �l <br /> .4- N <br /> y <br /> Cc600 rs <br /> S r/1N V NrDDp � <br /> �Le uU+eol oz5-� a = a a� I 'm <br /> . m S !2 =I <br /> o E 0= T� ' : a <br /> �i0QC L^ � '_ '' p <br /> -------- ': 'm 2 C <br /> 8 ; A`i <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o � 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- w m N D <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- f n v' <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g a 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 n o <br /> access to the abov escrib pre s at My reasonable tjpf for the purpose of inspection. m 80 . <br /> B vAA � ' <br /> ep <br /> 0 (p M N O <br /> SIGN HERE <br /> (si atu of owner I ing contractor) (date) c , <br /> ZONING ADMINISTRATOR 1 8 <br /> H_ <br /> TOWNSHIP PERMITS MAY .c�ioo � m <br /> BE REQUIRED <br /> 88888888rmn <br />