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;TY <br /> 'i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w t�'located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the M cBurnett County Land�Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and _ nregulations of the State of Wisconsi m <br /> C /arenc' e F d � {� r, c /t- m m ;f <br /> %WNER Prim 5 <br /> Contractor or Surveyor or Agent S.3 )Piero <br /> =SAbqq��dress t �� 2), Address <br /> tAru wi 2� <br /> City//State,Zip Code/ n Cry,State,Zip Code <br /> '7 (_� •lam'.{ <br /> Telephone Telephone �y <br /> Emergency/Fire No. and Road Name <br /> u <br /> Legal Description (as Indicated on tax statement) v <br /> Permit(s)Applied for: o <br /> o <br /> Dwelling Addition Filling/Grading Camping Unit o = <br /> o <br /> Accessory Building —74— Sanitary Privy Subdivision �U <br /> Garage <br /> // �` iQ �b )(.?f i4 <br /> Structure Use: f.D Ofi/lA C'Xr`S7�nG a.2 Xr�� rGroGe (,rlr <br /> (family me/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 3 �� <br /> 3. Show dimensions In feet ofthe following:(a)building to all lot lines,(b)building to center line of road,(c)building � � c <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 O h N <br /> dated by the owner. M , ot <br /> PLOT PLAN <br /> C <br /> ' T � <br /> C� o <br /> m <br /> v � <br /> J Z <br /> f <br /> oc � mmoagm <br /> ' . y9-� a. 3. am M <br /> coo <br /> P03 A .Z <br /> f U7 M m <br /> L" € O <br /> 8 a <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informa- = _ a a p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. gag <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 N <br /> access to the above described premises at any reasonable time for the purpose of inspection. qm i 3 g . <br /> 0 p n r <br /> b a N <br /> M N $ <br /> SIGN HERE a a <br /> (signature of owner or 'Iding ontract r) a <br /> ZONING ADMINISTRATOR (O 8 <br /> TOWNS P PERMITS MAY BE REQUIRED „ $ e o m <br /> 88888888ma <br />