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)tt County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator a •o <br /> APPLICATION FOR - LAND USE - PERMITS 3 ' <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 w <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 n <br /> regulations of the tale of Wisconsin, m d <br /> arrU 1"Grtile_* l/✓/9Y,vE 1t?rT c ° <br /> OWNER (P ase Print) Contractor or Surveyor or Agent <br /> -job 21 / ctr. &AoA-.3761 /Vo m' <br /> r <br /> Ad�{ess Atl�(ess <br /> /1 1)dU fie 15W5 / IG )I Gr — 5 y93U <br /> City, State,XP City,State, Zip Coe <br /> Jrj / Zd <br /> -;L 62 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> J r^ 0 <br /> Legal Description (as Indicated on tax statement) ro P�C� 1,0 4 !a f Z ° 0 <br /> U 1 � <br /> Permit(s) Applied for 0 <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> v <br /> Accessory Building �— Sanitary Privy Subdivision 0 <br /> Garage 1 <br /> Structure Use: ©Xl2 5,4c, f14 Idr,.el . I 0- <br /> (family <br /> (family home/cabin, garage,ad r ton, 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). a <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 N <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building .qz it <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 A <br /> dated by the owner. C 0- <br /> PLOT PLAN <br /> m <br /> /1�R rosy 3o r ?. <br /> 11 <br /> x <br /> ro <br /> Fh srr�r �' <br /> Cubiti 0 sizbwir <br /> Ir/r <br /> . <br /> z <br /> fl 's orate 6kr,idt:n <br /> i <br /> o c v n F m <br /> ,p_ D a-� m n N a m M <br /> 0 4 _ T� <br /> _ mi m <br /> N � � O <br /> 8 : mm M <br /> I 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 informa- H m H O <br /> lion 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. 1 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 <br /> m <br /> access to the above described premises at any reasonable time for the purpose of inspection. 8 roo <br /> m 3 <br /> ro ; vpp m I <br /> SIGN HERE—�.Lap.. "' _"' ' <br /> (signature of owner or building contractor) <br /> o : x : <br /> ZONING ADMINISTRATOR g <br /> H <br /> TOWNSHIP PERMITS MAY BE R OUIRED N N o o m <br /> 88888 $ 88 ) <br />