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Bumett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m -- �o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d a <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 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. m o <br /> fl�/ w m <br /> tib Zr.r } -Snj <br /> OW ER (Please Print) Contractor or Surveyor or Agent o ate, <br /> [{ d <br /> bra. e ( OX 'Z 7 <br /> Address Address ( p <br /> aJC.�rtWe- SG Zri <br /> 4C Stat Zip Code �8c We,k- nye City,State,Zip Code <br /> ome 1043 -4u4{z 413-71191 � <br /> Telephone Telephone <br /> Emergency/Fire o,7d Rodd NaySA �U! <br /> Legal Description (as indicated on tax statement) O <br /> Permits)Applied for: o <br /> 0 <br /> N ^ T <br /> Dwelling � Addition Filling/Grading Camping Unit <br /> v <br /> z <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage nny/ Cy� ��� �/ D <br /> Structure Use: 1,6H t iV �-LI wrtk I D fX / I /V o <br /> (family home/cabin, garage, addition, etc.) r <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). <br /> 2. Show the location of the well (W),septic tank(ST),and dralnfleld (DF). 0 <br /> M 3 <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building z c <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. N separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and } H <br /> dated by the owner. <br /> C I <br /> PLOT PLAN <br /> �i <br /> See diluoxeclOt, <br /> g <br /> b� jc wujT d <br /> Pr N <br /> tu� <br /> &e_ used <br /> � Z <br /> I D <br /> NN V fA r- DD <br /> 0 19r1 <br /> Vin [ O <br /> g c : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c m a a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of amll informs- _ u,m`n : O <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. I 8 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n "' o <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m 3 n . <br /> N V A N <br /> m � <br /> SIGN HERE zs c' F1 4E gHwa f <br /> (signature of owner or building co tr tor) <br /> ZONING ADMINISTRATOR 9 g <br /> ALk 1991 N. <br /> TOWNSHIP PER S MAY BE REQUIRED <br /> $ 8 888 <br />