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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d b <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v y <br /> OC <br /> 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 r applicable County Ordinances and the laws and 3 a <br /> regulations of the State of Wisconsin. �, m <br /> f <br /> OWNER Please PrintContractor o Surveyor or gent o <br /> .s.�.s Aeby Rd— <br /> Address <br /> Address — Adr �/IJJ& J A'r f il SyA� ' ( 4 <br /> City, State, Zipode City, State,Zip C <br /> ) <br /> & 259 - 72IR <br /> Telephone `'7 Telephone <br /> 3555 �r r4 RGLI ^ J� <br /> Emergency/Fire No. andFfoad Name <br /> Legal Description (as Indicated on tax statement) <br /> n0 <br /> Permits)Applied for: 3 �. <br /> N r <br /> TR <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° � <br /> GarageDC7/ /I�/ <br /> Structure Use: �b l l' <br /> (family home/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). o <br /> 2. Show the location of the well (W),septic tank(ST), and dralnfiaid (DF). 03 m <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. o a <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. m M t <br /> PLOT PLAN m 9 <br /> P10-F FLPAl <br /> � : <br /> 0 <br /> ] <br /> N N <br /> °. Jl <br /> ] <br /> o � <br /> N <br /> Ilse 0 <br /> Z <br /> A. Da'� anN <br /> `e <br /> aM <br /> o < `- Amo 0 ,p ] 3 <br /> f ] rrn: <br /> Z=- m <br /> N ! G) O <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- S : m a 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- wm H <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this in r- 8 m ,mN+ <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 1�,� 8 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 n N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (signature,of Ipwner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED Z"n qN9 o ' m <br /> 888888 18m <br /> �J <br />