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Burnett Counxy 7#10 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d ' o 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> m <br /> TO THE'ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <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. w m <br /> m m <br /> Ben C. Blair a o <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 28547 PalmharQ RrTarl <br /> m <br /> Address Address <br /> Danbury, WI 54830 <br /> City,State,Zip Code City,State,Zip Code <br /> (715) 866-8562 <br /> 1 <br /> Telephone Telephone <br /> 28547 PalmberQ Road <br /> Emergency/Fire No. and Road Name <br /> DCl. Government Tnt- 3. Rar_ 1 " T40N R17W- TY of TTninn <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s) Applied for: o C. <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> c <br /> Z o <br /> Accessory Building Subdivision ° m <br /> Garage <br /> Structure Use: rani far . n l v <br /> r <br /> (family homelcabin, garage, addition,etc.) � 000 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 10 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 9 <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 1 3 <br /> 3. Show dimensions Infest of thefollowing:(a)building to all lot lines,(b)building to center lineof road,(c)building 91 z o <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 N <br /> dated by the owner. <br /> C <br /> PLOT PLAN m <br /> I <br /> 1 N <br /> 8 0 <br /> SEE ATPACHED o ) <br /> m <br /> o � <br /> N <br /> r <br /> Z <br /> I <br /> ^_III <br /> � 0C - mmaagM <br /> > > og a m <br /> 33 2. : . S Wim' 3 <br /> P o <br /> ° In <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- 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit.-,,, 9 , 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 /> plicatlon.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> n <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> A <br /> " � <br /> SIGN HERE <br /> Wade Rufsholm 9/4/91 " . ' . <br /> 0: SO <br /> (signature of owner or building contractor) ate) e z <br /> ZONING ADMINISTRATOR S ` 8i <br /> TOWNSHIP PERMITS M BE REOUIREDc o m <br /> It$ 888rmn <br />