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...ett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator in - o o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> d O <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 5 <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 3 a <br /> regulations of the State of Wisconsin. w m <br /> v 4 u Avg �� e >! e/L/ <br /> � /''gyp <br /> OWNER (Pte�Print) //� or SuryeyororAge��tt o �; <br /> [��B_S f/ate � Ke �� 9 S 5" Nowc 1�� <br /> Add!ressuAddre�`3 <br /> S Gy I <br /> CityStat ,Zip Code City,State,Zip Code C <br /> Telepho a o Telepho <br /> ytbnk - �do ne <br /> - S'S'f-yF5,2 �j <br /> 6 - /-ios-3�3��'z __5 30 <br /> Enter 2V <br /> /Fire o and Road Name .� l <br /> y '1 /`Q'Ltt v <br /> Legal Description (as Indicated on tax statement) n <br /> m <br /> ^ <br /> Permit(s)Applied for: o o <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: _� _C�_1Se 2 nY61Z <br /> (family home/cabin, garage, addition, etc.) <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' <br /> 2. Show the location of the well (W),septic tank (ST),and drainfieid (DF). 11 03 rn <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building q `c <br /> Z <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 N <br /> dated by the owner. C t <br /> PLOT PLAN m ; <br /> t <br /> AM, <br /> ( L o <br /> r gs, <br /> Z <br /> ,o <br /> � p <br /> m pa� m aN cia' � p <br /> C l/eIJ rue 2 o ; z : M <br /> F T (n m <br /> � ^ m <br /> N Oma [ O <br /> $ mm M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs <br /> m no <br /> O. <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $m rn <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 09 o i <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> A N <br /> SIGN HERE <br /> (signature caner or building contractor) 1`_._._'_`' d tel — o <br /> ZONING ADMINISTRATOR r <br /> i, l MAY 1 61992 »»» <br /> TOWNSHIP PERMITS MAY BE REOUIR j 0089 o o$ m <br />