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Burnett Couetty7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; --i a <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 v H <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 <br /> regulations of the State of Wisconsin. <br /> / <br /> G L'r /S 3t 5 AAYO.n <br /> OYIF�(P/)SaserPr' f� �� L�L� Contractor or Surveyor or Agent o <br /> (p `J m <br /> Atltlress Address <br /> ✓!,- Ciro✓G �/ S. ��. S.J4/� 1 _, <br /> City tate,,zlp Code °Jt"�� City, State,Zip Code <br /> �1 <br /> Tblephond ,J '' Telephone / //// <br /> / �"'Wd's Tilt � �nNGLh J?tj �Ayapoux 74Q AI <br /> Emergency/Fire No. and Road Name PPF <br /> fc, 0-3 7,2-13a Q17-YA1Y?.'V ia/ Aeres 16 40CL'rX. O <br /> Legal tescription (as Indicated on tax statement) /o/ /pad _°. <br /> Permit(s) Applied for: �.oCa.Y4c.Q /n dcw 5 ? <br /> Dwelling _ Addition Filling/Grading Camping Unit S °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage ff I r <br /> Structure Use: (family <br /> �� <br /> �— (famiy home/cabin,garage, addition,etc.) I o <br /> 1A <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 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). a m <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 `v <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m n <br /> dated by the owner. C ( , <br /> PLw <br /> m <br /> 6 O a "or+b <br /> OT PLA a C <br /> Vy <br /> 3a a <br /> � I6\ � � 4 C1 <br /> o ' a o <br /> Z <br /> o <br /> \ Sef6a in T a m a g v <br /> N <br /> O /GItQ zo : IQ : _{ <br /> P e Thi a <br /> m <br /> a : <br /> i; O <br /> m C <br /> 8 <br /> I declare that this application(including any accompanying schedule)has been examined be o my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for tit i nd a racy of all informa- w m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g rt 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication. I agree to permit county officials chargwith administering county ordinances or other authorized person to have n 0 o <br /> access to the above describ p ises at n jid asonable time for the purpose of inspection. w 8 m <br /> m 3 n <br /> 00, <br /> N ^ H <br /> _ F7:3 <br /> � � 0 ZZFj11 <br /> N a <br /> SIGN HERE �� <br /> (signature of owner or bui g con ,te)� <br /> _—•.. _._ i i i p i �' i <br /> ZONING ADMINISTRATOR [ [ <br /> H <br /> TOWNSHIP PERMITS MAY BE REOUiIR I APR 2 4 V,5 X .o-.- 10 <br /> . <br /> J I 88s8888s <br />