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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the I c <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 o. <br /> regulations of the State of Wisconsin. w n <br /> a <br /> 'e Boni Q J A�oSe n f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o 1 m <br /> .?(671.2 reeD6r7- 40e m <br /> Add r as Address ' <br /> 11 M I.0 <br /> City,Atate,Zip C de City,State,Zip Code <br /> L <br /> Telephone MoSeQ �7 (' Telephone <br /> Emergency/Fire No. and Road Name a <br /> Legal Description (as Indicated on tax statement) <br /> n L7 <br /> 0 <br /> Permit(s)Applied for: o �- <br /> o = n <br /> Dwelling Addition Filling/Grading Camping Unit ?� <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision i = �- <br /> Garage LL 1_ , <br /> Structure Use: h C'ct i n �� �° 0 <br /> o <br /> (family home/cabin,garage, addition,etc.) MR <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 S <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)buildingZ v <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 m o <br /> dated by the owner. C I = <br /> PLOT PLAN in <br /> LaIce <br /> � I <br /> d <br /> _ <br /> 1 ) <br /> J <br /> O � <br /> /5O f ^ �- <br /> �lwe(1� 7 � <br /> 1 <br /> 1� <br /> � fZi F— 5� _tet <br /> a <br /> D o c m m n g <br /> m <br /> CN a = x <br /> 1- N . <br /> D ❑ OU-r ,1 DUSe o f i �!N a <br /> yq �D m <br /> o <br /> c <br /> 8 : A m : a <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- , = H m N 13 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ' g g <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.Iagree to permit county officials charged with administering county ordinances or other authorized person to have n N o <br /> access to the above ascribed premises at any reasonable time for the purpose of inspection. 0 <br /> yAAS$ <br /> z <br /> SIGN NER <br /> nature of wner or building contractor) (date) o <br /> II J: <br /> ZONING ADMINISTRATOR -Jf� >cU�Nlr�fi� - 8 ` ` <br /> MN~M NNM T <br /> TOWNSHIP PERMITS MAY BE REQUIRED NV NV NV c c m <br /> 88888888M <br />