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`ryZ. �LiYy�/1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm o 0 <br /> APPLICATION FOR — LAND USE — PERMITS w o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as E''bw',herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m n <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> v <br /> regulations of the State of Wisconsin. H <br /> TJID f�{aA &50 ° <br /> OWNEPlease Prin�t)) Contractor or Surveyor or Agent m <br /> �iISS/� 3 �f, I lC • LAI��ItJ�i <br /> %ddres <br /> Atldress lar�By0, State,Zip Cc de City,State,Zip Code <br /> Telephone Telephone lJ <br /> Emergency/Fire No. and Road Name l <br /> 0 <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> o <. <br /> Permit(s)Applied for: <br /> m r <br /> o^ ° <br /> Dwelling Addition Filling/Grading Camping Unit v <br /> Z o <br /> P <br /> Accessory Building Sanitary A Privy Subdivision } <br /> Garage <br /> J\'Tit/ J) d f�cY!i�01� 7 f 7('1n� �ATIY/C�Dni 1?2'��'ODfh <br /> Structure Use: 0 <br /> (family h me/cabin, garage,additl n,etc.) <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). 000 <br /> 2. Show the location of the well (W),septic tank(ST),and dralnfleld (DF). 11 o rn <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)buildingZ `v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m (� o <br /> dated by the owner. <br /> fA CT1 <br /> PLOT PLAN III <br /> rl11 ( C D <br /> 0 <br /> N <br /> oP7m mA ' FT <br /> � Da� c co 6' 9 <br /> < `Z a O M t0 3 <br /> Z io �. : Z,2 : 1 <br /> IT <br /> q Z <br /> 1 declare that this application(Including any accompanying schedule)has been examined by me and to the Dest 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 informs ` 'c i N m C <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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. I $ o <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this <br /> plication.I agree to permit county officials charged with administering count ordinances or other authorized person to have 0i7 0 : <br /> access to the above described pr ises at any reasonable time for a purpcpe of inspection. m 3 80 <br /> A � A <br /> SIGN HEREP i <br /> (data) <br /> (sig ature of owner or building con r or) : o <br /> � y <br /> ZONING ADMINISTRATOR <br /> N -� NNN • <br /> TOWNSHIP PERMI S MAY BE REQUIRED SEP N $ o c r <br /> 8 888i <br />