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Office of Zoning Administrator A o 0 <br /> Burnett Coupty 7410 Co. Rd. K, No. 102, Siren, WI 54872 0 3 <br /> APPLICATION FOR — LAND USE — PERMITS = o <br /> TO THE 70NING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 n <br /> Burnett County land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and m <br /> regulations of the State of Wisconsin. c <br /> 1'19 I) J GnSIPIAA/0 Sccf a <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 9$/a2 BI <br /> ,2 LAKE Ry <br /> Address Address <br /> phi V_&fa y N/I hH-83o <br /> City, State,Zip Code City,State, Zip Code <br /> (o�lv -3�i� <br /> Telephone Telephone ^, <br /> W <br /> Emergency/Fire No. and Road Name (� <br /> 0 <br /> Legal Description (as indicated on tax statement) <br /> 0 <br /> o �- c <br /> Permit(s) Applied for: � <br /> m r <br /> ° ° V <br /> Dwelling Addition Filling/Grading Camping Unit v <br /> 0 o <br /> Accessory Building Sanitary Privy Subdivision p M <br /> Garage <br /> _ r <br /> Structure Use: ° <br /> (family home/cabin, garage,addition, etc.) � <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O 3 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DIF). <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 Q <br /> measurement to the ordinary high water mark of lake,stream,or river. ned and M <br /> ° a I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be sigo <br /> dated by the owner. C t ' <br /> a <br /> PLOT PLAN M <br /> n <br /> Y' <br /> I v, <br /> a <br /> ni in o <br /> N <br /> o <br /> c <br /> � Z <br /> M o c m d a F m <br /> m. Da� mam a = a <br /> m m o m' <br /> Z <br /> = N ` In <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> O <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa. «, m N <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 $ $ <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 above described premises at any reasonable time for the purpose of inspection. m 3 8 N <br /> r <br /> m <br /> SIGN HEREFr <br /> gnature of owner orui mg Sentra Y ) o <br /> 8 <br /> ZONING ADMINISTRATOR T <br /> TOWNSH PERMITS MAY88 mBE REQUIRED ',I��I � I` <br /> �i <br />