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Burnell County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d W o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d 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 m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3. n <br /> regulations of the State of Wisconsin. H m° <br /> Lobc-kpcic_K � JA AA <br /> OWNER (Please Print) Contractor or Surveyor or Agent <br /> Z75L(Nn LA ICL lCoA2) <br /> Address Address <br /> W S T& R , 141z 93 <br /> City, State, Zip Code City,State,Zip Code <br /> �`�L - 7541 <br /> Telephone Telephone <br /> _5, .til c <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> ° <br /> Permit(s)Applied for: o °- <br /> m � <br /> Dwelling Addition x Filling/Grading Camping Unit <br /> o R <br /> Z o � <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: ��6E _ I o <br /> (family home/cabin,garage, additi n, etc.) 5 <br /> ppp ` <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0X I <br /> ]J <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). o l <br /> 2. Show the location of the well (W),septic tank (ST),and drainfieid (DF). 0 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 I - a <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. ) <br /> C <br /> PLOT PLAN )OT PL� m r <br /> I/(J I33< <br /> I N <br /> o <br /> 8 <br /> N <br /> m <br /> O y <br /> Z <br /> ( <br /> G <br /> mO c m m F t�fl <br /> M <br /> 91C 3 <br /> P F 0 : T M <br /> in <br /> N [ ii2 O <br /> g <br /> $ n < <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know) c I m 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- w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- C9 `a <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 a ree to permit county officials charged with administering county ordinances or other authorized person to have ia <br /> O '$O <br /> access tote bove described premises at any reasonable time for the purpose of inspection. w <br /> m 3 A <br /> SIGN HE <br /> (signature caner or Dui ing contractor) (date) o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY SE REQUIRED N N o o m <br /> $ $ $ $ $ $$ $ vi <br />