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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 03 <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � 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 n <br /> regulations of the State of Wisconsin. y m <br /> f <br /> OWNER (PIeasaPrint) /7 Contractor or Surveyor or Agent mL� <br /> �fllYlEs stud T<DStiLle W12WL,,nd . <br /> Address Address <br /> '76� to /19A/.y '5f <br /> Ciry State,Zip Code City, State,Zip Code r <br /> �An URS, w1 54830 ) I l� <br /> Telephone Telephone <br /> (7/5 ) /056 - 7ys-o- ��) <br /> Emer ency/Fire No. and Road Na - �.� i.41 L 0� '/,�� { 1 <br /> L,, S' c / t Ur'j l?, ;� 72 pr r=w 1 1 l <br /> Legal Description (as indicat o� n tax statement) <br /> P ct <br /> Permit(s)Applied for: 0 °. <br /> v+ r <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> v <br /> 0 o <br /> Accessory Building Sanitary Privy Subdivision - ° <br /> Garage <br /> Structure use: <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). o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (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 Z <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A y <br /> dated by the owner. C <br /> PLOT PLAN rvokthm <br /> 42100 <br /> iI t <br /> 3 � <br /> 0 <br /> (v(n0 W.V L. <br /> o <br /> �a75 '� <br /> 71) p yy <br /> ll�ji C <br /> ,� m <br /> m = v ' _aoa <br /> o D . m. N . A y <br /> /I ��. '�1611r4�GliL min'�ODUBIa� d,� ° f = T m <br /> = ` m <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- a m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ro <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $A $ <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 t7 <br /> access to the above desvrt�ed premise at any reasonable time for the purpose of inspection. w $ m <br /> ! _ m 3 n <br /> m as <br /> SIGN HER& , d E� <br /> (signature of owner or bur d` ntra 1 el o s <br /> ZONING ADMINISTRATOR / 8 <br /> TOWNSHIP P MITS MAY BE REQUIRED $ 0 0 <br /> N pN p p p <br /> 8$ 0 0 $ 0 0 <br />