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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m o <br /> 70 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 � m pQ <br /> Burnett County Land Use Ordinance, Sanitation Code, and wRh all other applicable County Ordinances and the laws and 3 n � <br /> regulations of the State of Wisconsin. „ � <br /> Snl�n l 1�-g�arevt HIIPn Mv-Ic w 1�,� a m ° <br /> f <br /> OWNER (Plea a rint) I/ 1 y ComradororSurveyororAgent o 3, <br /> TPd 6P �hP !lC' fC WI� IIC1 r1 m � f <br /> Ad�d7ress � ) Address l �, <br /> 1J(',9i/�.(' U'fa I.CNM LW {�e/ [,�2; �"Y�/8 q...1 <br /> City,State,Zi Code Cdy,State,Zip Code <br /> T phone '/ Tet��ppryrygqr�e / n <br /> ScI.tS 1 ACQ �c� • G : Lcg`�� I J�51 - yi- 16 SW%S.0 7�'>�n,�i <br /> Emergency/Fire No. and Road Name l <br /> Legal Description (as Indicated on tax statement) <br /> o � <br /> Permits) Applied for: o �_ r0 <br /> Dwelling � Addition Filling/Grading Camping Unit S � <br /> v <br /> z o <br /> Accessory Building Sanitary x Privy Subdivision ° � <br /> Garage <br /> Structure Use: � -shin <br /> (family home/cabin,garage,addhion, etc.) � I o <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 drainfieid (DF). � 3 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center Zine of road,(c)building � Z o <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. M separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and � `}, H <br /> dated by the owner. <br /> P <br /> PLOT PLAN M C}\ <br /> In �� <br /> �t <br /> i <br /> �5 � <br /> 0 <br /> �, <br /> � � ___ o <br /> k =. <br /> � � <br /> m <br /> 6 —tet � ^�S4Se <br /> 3e,k.3� <br /> �( � z <br /> 1 $ <br /> _ r � 33a � � <br /> � R`� Ta ��5� o�k hoc�.se /E,SI <br /> 3flt`',oe w�iy i.S Hca ' � <br /> -t sc <br /> i O � 0 g C rps <br /> �"_ D oc � mm ongm <br /> v na'� mam > mxt <br /> Z <. �: ? ma � � � <br /> � � � _ . � n <br /> 7 '-I m : <br /> . � , : m <br /> U O ^ O <br /> 8 a ; c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- � � m � 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- �: � 8 m u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I ) g 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 ermit county officials charged with administering county ordinances or other authorized person to have u, <br /> access to the ve described premises at any reasonable time for the Durpose of inspection. � m 8 � <br /> _ � m <br /> ` � ^ H <br /> _, �� � � <br /> SIGN HERE -� � ` '^ a E <br /> (si ure of ow r building contractor) �.� 1.111�- Idate) o x <br /> ��� �— '�'� J�� s <br /> ZONING MINISTRATOR V a . <br /> � N_ <br /> " TOWNSHIP PERMITS MAY BE REOUIR�� ��,n' &�o <br /> 'lig 888888, 8 <br /> `o <br /> _— — ;,� <br /> �� <br />