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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0M o 0 <br /> APPLICATION FOR - LAND USE - PERMITS3_ <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ro 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 /> PRvt Al2r t_k--D� n o <br /> OWNER (Please Print) Contractor or Surveyor or Agent 'o <br /> za75_i C-C-ObN <br /> Address Address r-- <br /> I�TSS�tZfr v'A 5,gyl U ����ANTSBuZs4y.l .`�`/ �L/I C3 <br /> City, State,Zip Code City,State,Zip Code _ — <br /> I/5' L/ % 7/S' ���X7.5 C` <br /> Telephone Telephone c� <br /> Emergency/Fire No. and Road Name <br /> U <br /> Legal Description (as Indicated on tax statement) o 0 <br /> C3 S7 <br /> Permit(s)Applied for: o <br /> Dwelling Addition 14.1 Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage ff <br /> Structure Use: � ,S'eQso t/ o <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 Ti <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). n <br /> 2. Show the location of the well ,septic tank S <br /> (W) p ( T),and drainfield (DF). 3 <br /> 3. Show dimensions in feet ofthefollowing:(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 n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m n <br /> dated by the owner. ] o` <br /> C <br /> PLOT PLAN <br /> CdC!%Pl� 9J� � <br /> �d/'C�'L <br /> IN <br /> N <br /> U J <br /> / 0 J ) <br /> s <br /> oy <br /> ZJ <br /> NN 1 <br /> �I <br /> o c mm12� <br /> n E RI <br /> Ea 1° 9 <br /> < z Z H OC�I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 9 <br /> m <br /> accuracy of all informs- w <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accu y f� mII yy O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ) f 25 ml N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 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 to permit county officials charged with administering county ordinances or other authorized person to have u <br /> m <br /> access to the above described premises at any reasonable time for the purpose of inspection. g m <br /> m 3 n <br /> A m <br /> SIGN HERE Me 'J <br /> (signature of o ner or building�r (datONING ADMINISTRATORj g ' <br /> N. <br /> TOWNSHIP PER TS MAY BE REQUIREDN N o 0 7S m <br /> 8888888 $ m <br />