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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; W o �o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Cade, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. <br /> _JC 2��/ JuR{�QGcIIQ II/�' CGJ FJ /GoP<ys n O <br /> f <br /> OWNER (Please Print) Contractor or Surveyor or Agent v <br /> I� Bvs -5'e Ti? 4us No <br /> Address Address <br /> PLy/w o u r/¢- R/I N s sz/c11- IiLJ�i,f4�i �Rte-t' [� <br /> City, State,Zip Code City,State,Zip Code 1 <br /> �l (o/..I -.SSS/ -x-/88 'S <br /> Telephone 4000 '`°t Telephone <br /> ,12d07 F-oah, 12d. as4- 3365 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) SCC /d P,4#7'O pp ?WN 4/0 R Al G- /S � <br /> _ � O <br /> Permit(s)Applied for: �O d-f/ V I 'o.2 ?.o �- <br /> (SN A/w NO) y 5 <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> z o <br /> Acceding Sanitary Privy Subdivision ° <br /> Garage r <br /> Structure Use: CMd/AJ <br /> o <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <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 drainfield (DF). 3 <br /> 3. Show dimensions In feet of the following:(a) buildIngto all lot lines,(b)building to center line of road,(c)building j z `v <br /> measurement to the ordinary high water mark of lake,stream, or river. o n <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. C fAt <br /> PLOT PLAN m <br /> SES 4 77�w-H 6-6 PLDT �`Avtl I C <br /> m <br /> 0 <br /> o �I <br /> jlX <br /> m <br /> o � <br /> r��s <br /> b �r lea-5 <br /> -Yrort �05� �6 r <br /> oc 200m on m <br /> Z qo m ,z 1 <br /> 21 <br /> cM <br /> a : i O <br /> 8 c : <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. 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- a m w . O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- [ n N <br /> mation 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 0 rN' O <br /> access to the above described premises at any reasonable time for the purpose of inspection. 3 8 9 <br /> m ` 3 n F <br /> SIGN HERE <br /> (signal a/_owner or-bui i contractor) �>� o <br /> ZONING ADMINISTRATOR J� <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 88888888ami <br />