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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (A ' 0 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 2 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the g <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. - <br /> N G <br /> V AAri GY �E' �- 3V a O <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> Address Address/ ./- �+ Address <br /> S/ , LL 2�G-1r ✓J�11t -T-5-6 rl f7 <br /> City, State,Zip Code City,State,Zip Code i <br /> � <br /> /2 <63 - d/Gy, <br /> Telephon d Telephone <br /> h <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) q <br /> � O <br /> 0 <br /> Permit(s)Applied for: o < <br /> Dwelling Addition Filling/Grading Camping Unit o 2 <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: ��1'�`�cl <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST),and draintield (DF). 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 <br /> 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 A y <br /> dated by the owner. f>f <br /> C <br /> PLOT PLAN m <br /> sr Ass _ <br /> 3 � c <br /> rn <br /> i - <br /> 0 <br /> _ <br /> a � . <br /> MjL <br /> � eoFT <br /> N( LoT <br /> R o c Tm m o a g 'MOm <br /> a =aw OR a <br /> < a o 5 0 3 <br /> -i <br /> ca : m <br /> 8i <br /> msi C <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- S a m m <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informa- <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 g m g <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. �' a <br /> SIGN HERE /1�i1 1� /��-�-�=" r X�'�i-y X99/ <br /> (signature of ner or building contractor) (date) <br /> / o : xl <br /> ZONING ADMINISTRATOR - Jl/'� �n )i A E 8 : . <br /> F <br /> TOWNSHIP PERMITS MAY BE REQUIREDNms c c m <br /> 3999 ' ss n <br />