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y1 .I", ✓ <br /> Burnell County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator to -t z <br /> APPLICATION FOR - LAND USE - PERMITS <br /> zi <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and rA <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 1 <br /> Burnett County Land Use Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and Q <br /> regulations of the State of Wisconsin. U 1 <br /> OWNER (Please Print) ? f� Contractor or Surveyor or A ern 1 — <br /> Atdrss 4 5' l�,nv.y1//A �GtITA r\t�GIGC �� �;n: �-�'� 49"'' S41,,? 14 m �� <br /> f� J Address <br /> Ciry,State,Zi ode, LT '>;14L"1,_ M� �&t <br /> r Clty,State,Zip Code <br /> '715— .5'L - 3 960 <br /> Telephone <br /> 3(-)r 4S �"l in.e y tea Tele P, ��z <br /> hon <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as Indicated on tax statement) c <br /> Permit(s)Applied for: 0 C <br /> < <br /> DwellingNr . <br /> Addition Filling/Grading Camping Unit o 2 <br /> Z v <br /> Accessory Buildin SanitaryC <br /> Garage Privy Subdivision ° 10 <br /> s <br /> Structure Use: V <br /> (family home/cabin, garage,addition, etc.) <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). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfieid (DF). 3 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building <br /> measurement to the ordinary high water mark of lake,stream,or river. FL <br /> c <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A `- <br /> dated by the owner. M w c <br /> , <br /> PLOT PLAN w � <br /> M � •' <br /> zt <br /> a > <br /> J <br /> J � w . <br /> bF o <br /> 55' _ o <br /> I ------------ <br /> I � <br /> 9 ordaga <br /> N: : z ; =0m <br /> = : c m <br /> i'Kf:A m c <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best 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• ' m <br /> tion contained in this application(Including any accompanying schedule)and I further declare that I recognize that this infor• m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a permit. I 8 A 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 permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> 38 <br /> A N <br /> SIGN MERE <br /> (signature of owner or but di contractor) (date) N' ' <br /> V <br /> ZONING ADMINISTRATOR g <br /> TOWNSHIP PERMITS MAY BE REQUIRED c c m <br /> 88888888umi <br />