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Burnett Counter 7410 Co. Rd. K, No. 102, Siren, WI 6487217 0� <br /> Office of Zoning Administrator m v -4 z <br /> 0 m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes 5 ° <br /> 9 y 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 A Cc <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wis'co/nsin. <br /> A, <br /> VELEY Td �L1.6 t I 0 V ELS 7 a � �0 <br /> OWNER (Please Print) Cont Cor Surveyor or A� ge_nt�r� o <br /> m <br /> Address _ <br /> S . Adm _ <br /> J��� UI,IdEfZ 'IU��K. dr <br /> City, State, Zip Code city,State,Zlp Code <br /> MR,S Koo SSS I Icl Mpg rnry SStf t .7 <br /> Telephone-7 Telephone <br /> G(z - 9Z-7-94�� , - �-Z--? -`,W93 <br /> Emergency/Fire No. and Road Name <br /> Y8-)O <br /> &_TLS 1�-Oftb <br /> Legal Description (as indicated on tax statement) co Cc,h �SkrV��ff <br /> Permit(s) Applied for: o- w+4 &'Gwf- (-0t7 -sj ,* r <br /> aist% <br /> - j o <br /> To . oeJ,F ((ef" <br /> 0 <br /> Dwelling o (D <br /> Addition Filling/Grading Camping Unit o <br /> Z <br /> v <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: <br /> (family home/cabin,garage, addition, etc.) = <br /> IRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 3 <br /> 3. Show dimensions in feet ofthefollowing:(a)buildingto all lot lines,(b)bulldingto center line of road,(c)building 11 o c <br /> measurement to the ordinary high water mark of lake,stream, or river. an o g <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A y <br /> dated by the owner. fill o <br /> PLOT PLAN �/a-T h _I ) 1 <br /> �r�i <br /> ►�of�l <br /> I <br /> s <br /> 01 <br /> Po <br /> N o F� <br /> 1 J <br /> V m <br /> rY) p H <br /> N <br /> z <br /> 13 ) tiotED Q <br /> x S N: 0 <br /> 74'. Fill <br /> n � mm �ag � <br /> f I a <br /> a N m 'Mn <br /> Z m -O - 0 ,2 ti <br /> P E J =! m SI <br /> _ m <br /> C <br /> I declare that this application includin an accompanyingschedule has been examined b me and to the best of m knowl- g i m m a <br /> PP 1 9 Y 1 Y Y o <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- ro p <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 u, <br /> access to the above descriD d pre at any reasonable time for the purpose of inspection. m 8 <br /> ro i 3 n p f <br /> I' -�^ m rt <br /> SIGN HERE �( Lao/ <br /> N w <br /> (signature of ownef or building contractor (date) <br /> o ? <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N o o x m <br /> $$ $ 88888x, <br />