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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U A c o <br /> APPLICATION FOR — LAND USE — PERMITS 3. ' <br /> 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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and n LA <br /> regulations of the State of Wisconsin. H m_ <br /> EUGENE k1E-ItIFL GAVZINSi<i M RLE TDM CVSCtR2F� a o <br /> OWNER (PleasePrint) Contractor Surveyor orA9ant o m <br /> 273(AP I�rgMLtT 259` Hw'4 35 m <br /> Address Address i <br /> m <br /> OPrKOFFLs- - MN . 5 51 28 It)E135T�YL tom. 54893 <br /> c ry, Stalk,Zip Coe City, State,Zip Code <br /> CCol 2 )-779 -9581 71s - 8fo6-818i r� <br /> r <br /> Telephone Telephone Z <br /> C.o Rd. — In <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) rtl <br /> 0 0 <br /> Permit(s) Applied for: o <br /> m � <br /> Dwelling x Addition Filling/Grading Camping Unit °- <br /> v q <br /> z o <br /> Accessory Building X Sanitary Privy Subdivision ° m <br /> Garage // N <br /> Structure Use: -f'AMtL4 CF}QIN ` GA(aRG1 6 <br /> (family home/ abin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <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 Infeet of thefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building iZ c <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. <br /> C <br /> ���p., I <br /> PLOT PLAN Ir)/ 1 �I/Ilr� �A <br /> 9-' G1 <br /> I Z t7 3 <br /> CC) B`� " u' <br /> to Ip O <br /> N <br /> o <br /> m <br /> 2 S <br /> 6 O <br /> r9 <br /> W <br /> m <J <br /> - --3 s too 1 r <br /> � e � <br /> �1q_T. � •ry � <br /> AeCESS D R1Yl- I o U d m a $ m <br /> A. Da� mEm a1Da <br /> 9 _ c O m 3 <br /> Lor 2 o no <br /> = ^ i m <br /> gip : G) o <br /> r 8 Nq rn <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowlO: 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- N m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- m u, <br /> matlon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 m 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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. - 0 m : <br /> T 3 n <br /> SIGN HERE <br /> (signature ofowner or 'd' ontr �^ 1 - ' o : Y <br /> ZONING ADMINISTRATOR GGG 8 <br /> TOWNSHIP PE ITS MAY BE REQUIRED APR - $NO O <br /> w NJ <br /> N N , N <br /> 88888 8 <br /> `' I <br />