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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w ; 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d O C <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m ; tS <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. H m <br /> �R1{C �`sDgxKF--r( a 0 <br /> OWti�R (Please Prim) Contractor or Surveyor or Agent o <br /> ',gyp iSM" Avg. So• <br /> Address Address <br /> So. ST. ►`�k►.- Mr.t. 55'0 <br /> glty, State,Zip Coe S City,State,Zip Code I <br /> 4s�-s�7z (klz)z�s-zqj o r <br /> Mep ne �� Telephone <br /> ?Q.2� mho 42D - <br /> Emergency/Fir No. and Road Name <br /> �l1510M !iC 141-s- 11 G 11-4.01Rt4 W AfAt-S .740 PCL 40.14-ioo 21 <br /> Legal Description (as Indicated on tax statement) Attasu L L;iva- OJkbku LoT it _ <br /> c> <br /> Permit(s) Applied for: o <br /> 0 <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> Zo <br /> Accessory Building ✓ Sanitary Privy Subdivision <br /> Garage n <br /> Structure Use: <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> 0 <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). O o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfieid (DF). a 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 `o <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 m y <br /> dated by the owner. C 0 <br /> DQ <br /> PLOT PLAN m <br /> f 1 � <br /> IT <br /> U) <br /> 0 <br /> 3zfm. r <br /> IZo i n N <br /> 0 <br /> Eb�jl' IOt � m <br /> n � � 4111 <br /> w (�" M <br /> ❑K 7d �.. <br /> i 1- <br /> 3SZ•7 r <br /> A o c m a F ren <br /> aoM <br /> v A < : '29003ro 3 <br /> o f m T� <br /> In <br /> jo <br /> m <br /> 8 i \ m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowlm <br /> - S m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- w m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize thatthis infor- fib"m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue i 8 <br /> 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- y, <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have m mo <br /> access to the above described premises at any reasonable time for the purpose of inspection. 8 n <br /> T 3 <br /> A w <br /> p N O <br /> SIGN HERE �= N <br /> n <br /> (signat e o ter or i mg contractor) "—";-- "".(a` } <br /> o : ? : <br /> ZONING ADMINISTRATOR g <br /> 111 `x'' 0"' 80oo �rn <br /> TOWNSHIP PERMITS MAY BE REQUIRED MAY 19 1992 N N . <br /> $ 8888888ai <br />