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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 - <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 0- <br /> o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 0 m <br /> Burnett County Land Use Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n <br /> o � <br /> regulations of the State of Wisconsin. w 9t O <br /> c <br /> GaAjt nA00NZ a o <br /> OWNER(Pleaa Print) Contractor or Surveyor or Agent o m <br /> -72 2`� MoA) RA 63 L-AJ a °Q <br /> Addt b/N It M Aj S S Address <br /> City, State,Zip Code 1q z-o q Gr J City,State,Zip Code <br /> f Z � � <br /> Telephone Co Telephone <br /> Z 9 3 I <br /> Emergency/Fire No. and Road Name <br /> RISTa2y Sr Y l9 \4 3/4 P ZS9 St �/T40 -20 <br /> Legal Description (as Indicated on tax statement) P C_ L #— y O t !4 _O`/ ' ioZ9 O a <br /> P c, J- f o J l_o T— Y o <br /> Permit(s)Applied for: N <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o ° <br /> Z o <br /> 0 <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: � ' r"rr� r <br /> o <br /> (family home/cabin,garage, addition,etc.) .4 <br /> G <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). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 <br /> 3. Show dimensions Infest of thefollowing:(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. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and ,� H <br /> dated by the owner. C ' <br /> t <br /> PLOT PLAN - III r Z <br /> 223 Z <br /> L <br /> Z O � <br /> ?S <br /> O ' <br /> m <br /> O Q <br /> M I 0 <br /> —O C <br /> z <br /> z"L9, 5 <br /> 1 ,//-- <br /> I <br /> u o k ? m 3 <br /> If op ..I P i o Ty Z <br /> m <br /> M g 3 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> forma <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- » G): <br /> C <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this mit. I m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ $ <br /> further accept all liability ich may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication.Iagree to pe c unty officials charged wi ministering county ordinances or other authorized person to have ? ro g m <br /> access to the above d crib premises at any rens ale lime for the purpose of inspection. <br /> LfA <br /> »; n <br /> SIGN HERE (date) _� c <br /> (signs pro of wnerpyj 'ding contractor) \ <br /> ZONING ADMINISTRATOR <br /> i - TOWNSHIP PERMITS MAY BE REQUIRED - I rn moos t <br /> AUG 23i �91 i'iljjl gssgasss ! <br />