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Bumett County 7410 Co. Rd. K, No. 102,Siren, WI 54872 Office of Zoning Administrator d m o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m \ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the A c <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. w m <br /> r m <br /> ( ¢v3 BL�ck.0. �t�� fs�cJ G�r�ST k-0 a O <br /> 0 R(Please Print) Contractor or Surveyor or Agent o <br /> 40 \�uw 51A\r S4s� no\)I" \-AlpeAddresRa <br /> %k- as,k",N� �4yk r Address <br /> �t oo �1`A <br /> City,State,Zip Codes 5 � �CpytS�a� Zip Code `h <br /> Teleph rte Telephone _ <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o QJ <br /> Permit(s)Applied for: c <br /> o <br /> Dwelling Addition Filling/Grading Camping Unit 0H ° h <br /> 'o <br /> Accessory Building Sanitary Privy o Subdivision � <br /> Garage <br /> Structure Use: o <br /> family home bin,garag , addition,etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 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 `o <br /> measurement to the ordinary high water mark of lake,stream,or river. O n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. C <br /> PLOT PLANW�V V�i�-Y �a Q,-- G Ut�f 01 `V ► ��t �(� 5 ('-5 �J <br /> co <br /> AaCJ-)f2 brawl lVC <br /> N <br /> O y <br /> N_ <br /> O I , <br /> J � <br /> l <br /> f <br /> on c m m o a g m <br /> OLD. 110 N a = M <br /> o y <br /> � T <br /> ctk ; C <br /> a- i gym : a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a- � 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- 0 <br /> tion <br /> m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Oro iX <br /> motion 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m 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 u, <br /> access to the above desc ' ed premises at any onable time for the purpose of inspection. m ; 3 82 <br /> A <br /> //�-j��� 1 q m v a <br /> SIGN HERE <br /> (signa�ture,sf owner or building contractor) (date) <br /> r l <br /> ZONING ADMINISTRATOR I) n FLAtj i" ) g <br /> TOWNSHIP PERMITS MAY BE REQUIRED 55800 <br /> 999999 S <br />