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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U) -1 a <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> o (5- <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 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 Code, and with all other applicable County Ordinances and the laws and _ <br /> regulations of the Stat f Wisconsin.. <br /> � f <br /> OWDNER(Plea <br /> s <br /> e Perri ) Contractor or Sl rveyor or A ant V J m <br /> —1 �i'� IJl�i;l 1 ,Y'k' 7J� LK • �L-1. m <br /> Atl�ess Address <br /> iA a[ <br /> City, State,Zip Code City,State,Zip Code v 4� <br /> Telephone Telephone S <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n ct <br /> — o <br /> Permit(s) Applied for: o �- <br /> m o (1 J <br /> Dwelling Addition Filling/Grading Camping Unit <br /> 0 `,1 <br /> Accessory Building Sanitary 0 Privy Subdivision } ,(— <br /> Garage <br /> Structure Use: - <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). C o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 93 v, <br /> 3. Show dimensions Infest of thefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building 11 it <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andm I ti m <br /> dated by the owner. C y j <br /> PLOT PLAN <br /> m lr, <br /> U) <br /> C <br /> U <br /> ° Is <br /> I ? SMI CIL,e- l t JO t� � <br /> up�- <br /> SC y�/CC- , �? ' his W45 I,)-r <br /> �fi sly-n'��^" <br /> o0Tmm day -0 <br /> rt ZdNa � n H } = a <br /> 7h2-:se l� emacs z 5F 0 0. a3 <br /> "' <br /> P M <br /> Pte : Trn : m <br /> ui G) no O <br /> C <br /> 1 -e a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my formaknowlo 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- yy m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this init. I 75 ro <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g A 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- N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have m 8 m <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 0 $ N <br /> m p> <br /> SIGN HERE a a <br /> (signature of ownerorbuilding contractor) (date) c x <br /> ZONING ADMINISTRATOR ?-7 tiw;991\ 8 i <br /> TOWNSHIP PERMITS MAY BE REQUIRED 90 P o 'p S m <br /> . <br /> L88888888rn <br />