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6-1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W m -. e <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d Q <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c <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 (S <br /> regulations of <br /> the State of Wisconsin. <br /> H m V 1 <br /> fl. rnl� 5 <br /> 12619. ��1�1 <br /> n f <br /> OWNER (Please Print) Contractor or Surveyor or Agent m <br /> RT 1 3oX X161-C 0 <br /> Address Address I <br /> C,h,rnew� `al► ,� Uj sy,Z9 rc <br /> City, State,Z� City,State,Zip Code <br /> 115 ?2(p ly4 8 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: o <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit °- <br /> v <br /> Z a <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage / 1 LI <br /> Structure Use: Gamowt n"� xQ3l r <br /> 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). <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (DF). C 3 <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 v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and H <br /> dated by the owner. C O <br /> PLOT PLAN / M g, <br /> 1 <br /> W � <br /> �X 3 �, <br /> k1 o 9- <br /> jai, s <br /> 411 <br /> t <br /> z8 A \ <br /> v-hlr�y�r <br /> 2y/ j91.�g' p <br /> o c c� m m � , MM <br /> N. y6� m6N a = 21 <br /> f v <br /> 0 e : <br /> —1-..... o T rn, M <br /> m <br /> L" € c� 2 o <br /> g n c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know$- m <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- y!m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ism N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m 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 have0�o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8• <br /> T ! 3 n <br /> m ? v pA a <br /> e • ypp <br /> SIGN HERE <br /> (signature of owner or di or tr (date) o = <br /> ' <br /> q g <br /> ZONING ADMINISTRATOR <br /> TOWNSH P PERMITS MAY BE REQUIRED0 <br /> N ««9 m <br /> N N 0 <br /> 88i3 $ 8888tmn <br />