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C'�� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m o <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 State of Wisconsin. H m <br /> JACK W-r KA'rf/E,Q1NE PE7_EXS'0A1 y6NDEP.5e)1V C49NS7_)S"C 7_11" 04 <br /> n V <br /> OWNER(Please Print) yor ongntR11/96 Stdi55 CiALETX-,> C/ontrsct,or orSu « rAP <br /> Ad�ress n <br /> m A <br /> Address '' / <br /> JHELL LAKE W/. 5//868 SHELL LAKE Wi .Syg7/ i <br /> C'��ii,Stat ,Zip Code C' Stat ,Zip Code <br /> (7/sj ;'6F- 770# �is) N6g -7'1115/ 90 <br /> Telephone Telephone <br /> Sw -sc Sex- as 3tiN - )itiU) <br /> Emergency/Fire No. and Road y�me <br /> /= = n <br /> U9/ Su dR nr Z,6_7_ <br /> RZ) <br /> Legal Description (as Indicated on tax statement) <br /> o O <br /> Permit(s)Applied for: 0 -C- <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 'o <br /> AccessQnLBuilding Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: C7/}4ACvE 5 <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). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (DF). 3 m <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 `v <br /> measurement to the ordinary high water mark of lake,stream,or river. 0 4CA <br /> 4. If separate plans are submitted by an architect,engineer,builder,cont r ctor,etc.,the plans must be signed and <br /> dated by the owner. <br /> PLOT PLAN t <br /> N�� cNe) <br /> �1 <br /> (V,/ <br /> L <br /> RAGE ry o I <br /> w <br /> - --� -0 <br /> tD'ecc <br /> 32 ,tjV �V_ o to 13M <br /> f <br /> 32 p <br /> 0 c m m a F <br /> m <br /> 40acxET 9 <br /> o � maam ; <br /> Pr`P ryas IVdf-MJWN, o E Ty <br /> . E zr <br /> ,•2 c _ m <br /> p Y'n nom : o <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a. <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- vi <br /> O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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 $ m $ <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. $ <br /> W <br /> SIGN HERE �' � ' ' <br /> (signsof owner o ilding contractor) (date) o <br /> ZONING ADMINISTRATOR �� g <br /> TOWNSHIP PERMITS MAY BE REQUIRED CIn ra -8 9 o o 9 m <br /> 88888888m <br />