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� / (• "i Y` I <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator P-�c � O o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and o S1 <br /> c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m „ O <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 m <br /> w <br /> o. <br /> OWNER (Pleas Print) Contractor o — o <br /> Apdress <br /> ..Ji rt J r —7 Address <br /> City, State, Zip Code City,State,Zip Code <br /> Telephone, r Telep e v <br /> Emergency/fie 0.ani>,�io,pd Name <br /> 7 b �'� � J �' �'9 f/�t � °. e_-i./l�.Y/✓ �.��-�� lam' <br /> Legal Description (as Indicated on tax statement) o <br /> n L7 <br /> Permit(s) Applied for: a <br /> 0 <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o 0 <br /> T (� <br /> Z g <br /> Accessory Building Sanitary (Privy Subdivision ° j � 1 <br /> Garage I- <br /> l/ <br /> Structure Use: I- <br /> `7 'Irl ! 'sem e Ll I,) <br /> (family home/cabin,garage, addition, etc.) ✓� <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (DF). 3 <br /> 3. Show dimensions In feet of the following:(a)building toall lot lines,(b)building tocenter line ofroad,(c)building <br /> an Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. an o o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc. th I n ust be signed and <br /> dated by the owner. M C <br /> C <br /> PLOT PLAN <br /> .��41 <br /> j / s <br /> / 0 <br /> a <br /> — <br /> W <br /> •i�e.� SYS Q' '� �-�-� -�-.�` <br /> V t LQ r w la� I' i lu) x 0,1P 4 <br /> u� �S,, L TVI oU :?1.1) v <br /> �4 P A K. `�J�� D a� <br /> i � M <br /> a N � W <br /> S mC000 r <br /> r9G`�ITIOl1 J f'I�m,`t— �eSrAYe �LL�C��ry� �yTZ :S���rrl�t'�f'cY ��re �� o � � i i M <br /> 1 7C Tl l '47�� � .:0 �F d ° -lect1:21'�e. 2 : p <br /> LC7�/Nu`.0 P97Fe ccGn e+te cActPle > �,r C ot7lrrr 13 e,�)lt C <br /> I declare Ih t this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c m m S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- y, m p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- A $ 'm <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 pe unty officials charged with administering county ordinances or other authorized person to have N <br /> access to the above,06e5^ed premi5olat any reasonable time for the purpose of inspection. m 8 <br /> � A <br /> SIGN HERE 17- <br /> (s gnaturof owns or buildin coptr t <br /> ZONING ADMINISTRATOR �� �� � 8 . <br /> TOWNSHIP PERMITS MAY BE REOUIRED ' I <br /> N N N N O O <br />