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OR (tyap <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0 -- a <br /> APPLICATION FOR — LAND USE — PERMITS3, <br /> m 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 w �, <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <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 /> .rF'Y�vr✓ W. Li`r�S T7Lir�Sor� ,C3�r 4C e %/�om4.5 a f <br /> OWNER lease Print) Contractor orSurveyororA ent o m <br /> Sou th , r a ria <br /> Ad ass Address r <br /> Sirrri �i �1J (� <br /> City, State,Zip Code City,State, Zip Code } <br /> ' P9 3y9.s's>i T;J' <br /> Telephone - Telephone <br /> �y5os� W ! lam's <br /> Emer ency/Fire No. and Road Nam <br /> saY� s Ak yag �� s wYL. sc lP, T3�/U- 12 l y w <br /> Legal Description as indicated on tax statement)—��—� ° F— <br /> o C <br /> Permits) Applied for: 0 �; C <br /> Dwelling Addition F inn/(`,rAdjnn Camping Unit S <br /> v <br /> Z o 1 <br /> Accessory Building Sanitary Privy Subdivision Via, <br /> Garage 3 <br /> Structure Use: �yf a � klat 1(°" e A(O p <br /> 0 <br /> (family home/cabin, garage, ddition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0i1!yI 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 00 \ <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 03 m <br /> 3. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)buildingto center line of road,(c)building Z F c <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 m y <br /> dated by the owner. C I U <br /> PLOT PLAN m 51.) <br /> G <br /> f ' avgcD�s z <br /> I t <br /> w <br /> NT <br /> = rn <br /> m <br /> n_ <br /> I <br /> s If <br /> o. <br /> ° .0 :2 <br /> V > > o m <br /> I( \(10° < n" i Z H ° <br /> I, <br /> 110 <br /> o f = T� . <br /> joC <br /> g : mm p <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> i m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- rA n 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. 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 a <br /> 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. ° <br /> m O A H <br /> nn /fin m m a <br /> �/� <br /> SIGN HERE—�! a <br /> (� (si at a of owne r buildin tractor, (date) c x <br /> 8 <br /> ZONING ADMINISTRATOR i <br /> TOWNSHIP PERMITS MAY BE REQUIRED GG rn u P . O <br /> 88888888 <br />