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t11 <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 /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 71w <br /> ° U1 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m 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. m <br /> >� O S S S Pti Se ir./ Sou /�I �r�i' <br /> OWNE3R(Please 8- <br /> A C Contractor or Surveyor or Agent o <br /> o gg11 ten(( m_ <br /> Address Address <br /> _41 1411V -e6l0h s /YI s/,�CZip Cati <br /> City,State,Zip Code City,State, de <br /> Telephone Telephone <br /> E erge /Fire No. a�d Road NamePS <br /> n / <br /> O $" IfINcS <br /> pi'lleS S9G/PwS <br /> Legal Description (as Indicated on tax statement) R <br /> Permit(s)Applied for: 0 0 <br /> 7 » <br /> m � <br /> Dwelling Addition 4— Filling/Grading Camping Unit S <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage (��/ <br /> Structure Use: 13 / �� / rPe -) 1 'Q(' fp-1 0 <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 Ul <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 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. n o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andH <br /> yu <br /> dated by the owner. fA <br /> C <br /> PLOT PLAN m v <br /> 1 VH <br /> O <br /> O I� <br /> m <br /> � 1 � <br /> vi <br /> Z <br /> 31 <br /> m o c m m a T <br /> v 33a� maH } <br /> <. �. i 'Zm oM 3 <br /> Z o : mQ : i <br /> j <br /> O i N D <br /> m <br /> LU�_ ` i c� o <br /> (` � a , [ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- `(� o I m 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- c h m O <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. 1 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 <br /> 0 0 '. <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 90 <br /> 8 A a <br /> SIGN HERE g RI <br /> (sign a of own uIlding contractor) (date) <br /> ZONING ADMINISTRATOR J./!v" /c - g ': j <br /> / TOWNSHIP PERMITS MAY BE REQUIREDH <br /> N N M <br /> � . oo � m <br /> ggggggggN <br />