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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m o ' o <br /> APPLICATION FOR — LAND USE — PERMITS 0 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 6 <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 m <br /> L�,vA�) T)D�2[5 LY�gTBfr __ f0 <� LrSK- a W f <br /> OWNER(Please Print �141CLs [�jf Contractor or Surveyor or Agent o <br /> 7/q AJ- t7�Ai <br /> Address Address <br /> City, State, Ztp C e City,State,Zip Code l <br /> N� I <br /> Telephone Telephone <br /> V-73 scuff-s <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Q.J <br /> Permit(s)Applied for: o` -4� <br /> Dwelling -'T Addition Filling/Grading Camping Unit o ° <br /> v <br /> z ° V\Accessory Building Sanitary Privy Subdivision <br /> 0 0 <br /> Garage — <br /> Structure Use: 4R-a;u 4 <br /> (family home/cabin, garage,joldition, etc.) — <br /> ' 0 �� W <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) v` <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <br /> 2. Show the location of the well (VV),septic tank (ST), and drainfield (DF). '113 c� <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 c <br /> measurement to the ordinary high water mark of lake,stream, or river. o O o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and S H' <br /> dated by the owner. C <br /> PLOT PLAN % S <br /> s <br /> ������'� � � �e���cr�en�o7">°Xis�i2� �r4c TuNe • ; <br /> / <br /> J� �� wG,v <br /> ( I N <br /> O <br /> G <br /> N (� <br /> ti <br /> z <br /> I � <br /> w <br /> o c m r p o a F m <br /> F4 C 00 SO 03 <br /> �. Dai acN `int a <br /> 2 m o m Z : 1 <br /> f0 Tn M <br /> o <br /> g ? <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S o 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 m D <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 9 m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a Dermit. I 80 g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ut <br /> access to the above described premises at an reasonable time for the purpose of inspection. m 3 8 <br /> o R A H _ <br /> m <br /> SIGN HEREH ' a <br /> ( ignature of ow bu g co (data) o <br /> ZONING ADMINISTRATOR jut <br /> 8 <br /> I » <br /> TOW SNIP PERMITS MAY BE REQUIRED <br /> 8 8 8 <br /> (({�(� `/7T <br />