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1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w A -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS v - <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 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 /> 0 <br /> regulations of the State of Wisconsin. w °» <br /> RZnR/C/A 5-44,0 IoNSC7 A.) a f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o Z <br /> .3/7/� DVit/HHM Lflee <br /> A ress Address <br /> /ten WL <br /> City, State, Zi ode City,State, Zip Code <br /> 6S`1- a7 /!� <br /> Telephone Telephone (\ <br /> � -70 D Ld <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> �- <br /> Permit(s) Applied for: o� O <br /> r <br /> o <br /> Dwelling Addition Filling/Grading Camping Unit � <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision i } `Z O <br /> Garage � �t�, ,�/ <br /> Structure Use: ����I =/��h ��X �u�'"W — 0 (� <br /> (family home/cabin, garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O oo' <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 w <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 o <br /> measurement to the ordinary high water mark of lake,stream,or river. c <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. <br /> l <br /> PLOT PLAN IMII to <br /> u� U " Cup s <br /> e'4S <br /> �-ISo_ r�llic;a9 ex,�� lO( ��ii 9 ° _ y <br /> �• m I <br /> ConC�ef�- a ro <br /> Int <br /> m <br /> O y <br /> Iw <br /> Z <br /> I^ <br /> J <br /> U.) <br /> o c m o n F <br /> n 9 m <br /> < ! m o0. 20 <br /> m m -t <br /> � i <br /> e m <br /> N : � 2 ` c <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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 at this infor- 8N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize thm N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ A 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- iw <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have 0 . o . <br /> access to the above described premises at any reasonable time for the purpose of inspection. w <br /> SIGN HERE « � <br /> (signature of o o di rector) adate) <br /> ZONING ADMINISTRATOR <br /> TO NSHIP PERMITS MAY BE REQUIRED U $ o o m <br /> 8888888 ai <br />