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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; 'Vo 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and ^ r� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. <br /> /-rvv� e✓uc'rzvt �i-ty'e J 1�'/ ca £ <br /> (IINER lease Print) Contra' o� or or Agent o <br /> t',C7 - g0 3`t('0 l/ m <br /> Address Atldress <br /> C , >~Qr� Lvt's r 82�. l — <br /> City,State,Zip Code City, $ i Code <br /> -71 i 4S-t 2400 l , <br /> Telephone Telephone <br /> f <br /> J <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) La T 1 -2- 171 4 N t cwVjoy rtc r o C <br /> Permit(s)Applied for: Cao - o. o <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z p <br /> Accessory Building Sanitary Privy Subdivision ° � <br /> Garage <br /> r <br /> Structure Use: Ga�+ � n f{�f��, Jlz1 <br /> r <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 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 c <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 y <br /> dated by the owner. fA 0 <br /> C 1 <br /> PLOT PLAN m <br /> J � ( <br /> 0 <br /> 0 <br /> m <br /> o <br /> m <br /> Lo-t 1z 7U <br /> '.l A(e AL f z <br /> V <br /> it <br /> �Z <br /> m o c J. m m a g m <br /> M m ; <br /> P cay[ m <br /> o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m m D <br /> 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I go 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 3 u <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> m 3A <br /> m m <br /> SIGN HERE <br /> (signature o o ner or building contractor) (date) a <br /> o : x : <br /> ZONING ADMINISTRATOR . <br /> TOWNSHIP PERMITS MAY BE REQUIRED $ o <br /> 8$ $ 9 <br />