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Burnett Cgunty 7410 Co: Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o �o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and N <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 0. <br /> regulations of the State of Wisconsin. y <br /> DOUG LARSOIJ c <br /> f <br /> OWW(�as jgrrt 3S I Contractor or Surveyor or Agent o <br /> Adgess R � 1 ', s4po ' Address <br /> City,St Is,Zip C de V City,State,Zip Code C'' , <br /> T5- 268- MCI xJ <br /> Telephon \ <br /> ��ayLt F _ 5ASS L .RD Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> `0 ct <br /> Permit(s) Applied for: o °. <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit 6 <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o m <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) l <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 311 N <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 Z `a <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 H <br /> dated by the owner. C <br /> PLOT PLAN m <br /> ( � m <br /> O <br /> N I <br /> o <br /> I' <br /> m <br /> w <br /> .11 <br /> I <br /> n <br /> o mvt � rnrna ,: <br /> m c <br /> mVi Zm0M03 <br /> o E T z <br /> P <br /> g c' : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S In <br /> 3 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all intorma- Fn m w C <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ,b"ro N <br /> mation 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 Cf o <br /> access to the above described premises at any reasonable time for the purpose of inspection. - m 8 m' <br /> m : 3 n <br /> /A mE m ap w f <br /> t •• Lc._ N l N O i <br /> SIGN HERE <br /> (si ature of owner or building contractor) o x <br /> ZONING ADMINISTRATOR i 8 ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED JUN Z 4 I $ o o <br />