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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U m c o <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 C. <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <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 w m ! <br /> Kena ori ra seT� 0 ) $ <br /> OWNER,(1 PI a Pyjnt)`rt rn Contractor or Surveyor or Agent o - <br /> � C{ ,EM7J m <br /> AddressL /I^ Address 1 ' <br /> ►ha + I`4 <br /> City, State,Zip Code J�S�129 City,State, Zip Code <br /> 2 <br /> Telephone 7 Telephone t� <br /> 1qyl - z - <br /> Emergency/Fire No. and Road Name a / � i C �+ �) ( / <br /> Legal Description (as Indicated on tax statement)-vpyt La•�ct, dj f0 F7 0 �+ <br /> Permit(s)Applied for: o °- <br /> Dwelling Addition K Filling/Grading Camping Unit S <br /> v <br /> z o <br /> Accessory Building Sanitary Privy , Sugdivision ° <br /> Garage (`at Y (g ��gl ori <br /> Structure Use: 1oLd boo� I 5 <br /> (family home/cabin,garag , addition,etU ^ &X(.S S a tN 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> A <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0' <br /> 2. Show the location of the well (W),septic tank(ST),and dralMield (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(a) bulldl4p9gtoalllotlines,(b)buildingtocenterlineofroad,(c)building Mill 'Z c <br /> measurement to the ordinary high water mark of Ia%e,stream, or river. . o g <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. <br /> PLOT PL <br /> 'f.z / r <br /> 45 <br /> IY4 <br /> Vali <br /> y� +gq � j <br /> \OCi ty t o <br /> I � <br /> z <br /> ly <br /> rn <br /> - _. ._ fY< : Zm53rrjf1 m <br /> CCJr _ Nm <br /> c = o <br /> € i c <br /> jin . <br /> ? <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my ko � m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all inf = a m N O <br /> [ m N <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this mation I am providing will berelied upon by the County of Burnett Wisconsin in determining whether to issue a perfurther accept all liability which may be a result of the County of Burnett relying on this information I am providing in thplication. I agree to permit county officials charged with administering county ordinances or other authorized person to 05 <br /> access to the above ascribed premi s at any reasonable time for the purpose of inspection. m 3 8 <br /> SIGN HERE <br /> s/' u w�J/�Sf�r building contractor) / =(datd <br /> ZONING ADMINISTRATOR v `�' '" -\ - ^� 8 <br /> e M M N <br /> TOWNSH RMITS MAY BE REOUIRE[ I I + prr <br /> JUL <br /> UU N M M T <br /> u <br /> 0 8888 <br />