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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W0 a <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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. <br /> Dale Merry � <br /> m <br /> LL m <br /> c <br /> t � ,Is � N /,> �Acfve a o <br /> OWNERSPIea7frint Contractor orSuryor rAgQent o £ <br /> _ 1933 f � rQNgQ .4vt km2 417 YederbI01 m <br /> Address Acl etss <br /> 3?, P,*., I. NlN SS/i9 ` ' retJ . Lir S SY6 �L <br /> City, State, Zip ode City,State,Zip C de <br /> 1 53 - 23 V _ <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> S/7`T38 JAS/1 g <br /> Permit(s) Applied for. 1 t2 CSM V y P /SY =' o ' <br /> �/N 616 fz hof �) 0 <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z T <br /> Accessory Building Sanitary 0 0 Privy Subdivision <br /> Structure Use: /1 4/4 <br /> ra E CN/ 7 <br /> r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) G <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 3 <br /> 3. Show dimensions in feet of the I ollowing:(a)building to all lot lines,(b)building to center line at road,(c)building � o c <br /> measurement to the ordinary high water mark of lake,stream,or river. In 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. M o <br /> C �^ <br /> PLOT PLAN to I l <br /> m , <br /> OA <br /> 6�VA66 <br /> , m <br /> 0 <br /> L CC r� IN <br /> o ( <br /> 11�0 3A <br /> Gmttt f <br /> O <br /> 10' <br /> V 0 o c m m n n m <br /> o <br /> c �a`� m' aH ' AS <br /> Z ai o 0. 10 3 <br /> Maddy L P� Kc- o ; T : M <br /> M <br /> m � C <br /> 81 mW <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> mS <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- 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 ` 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 <br /> access to the abov ascribed premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE <br /> (signature of wrier or building contractor) (date) v <br /> ZONING ADMINISTRATOR 1 f g ': . <br /> � � a uwosT <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> $ $ $ 88888tmn <br />