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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator n v y z <br /> £ o <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m = <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. y m <br /> Lee 4 /e.Ve Sr-/ n = o <br /> NER Plea rirn O f <br /> ( ) / /-� p Contractor or Surveyor or Agent o <br /> X1730Arrwfcly. Kr1 <br /> f p � I <br /> A reser / SGi b 9 Address � !Z` <br /> Zt <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Pj <br /> Enter encylFire No. an Road LNam/e- <br /> �� ! ;n �-'L 2�4_CJr <br /> Legal Description (as indicated on tax statement) o rti <br /> 0 <br /> Permits)Applied for: o <br /> w � <br /> Dwelling Addition Filling/Grading Camping Unit o 0 <br /> v <br /> z a <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: 7 �'r '( p 6�(� /` L/0 r <br /> 0 <br /> (family home/cabin, garage, addition,etc.) � J <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 G C� <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 dralydield (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 in ' <br /> measurement to the ordinary high water mark of lake,stream, or river. o n <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and O = <br /> dated by the owner. m C <br /> C ' <br /> PLOT PLAN m Q C <br /> S <br /> co <br /> b o <br /> O <br /> _ <br /> o <br /> I� <br /> s = <br /> o c m m n g m <br /> � = a <br /> C w a <br /> P . Tw M <br /> m <br /> g ` I Am ' ? <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know[- S ; sm <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- <br /> mation I am providing will be relied upon by the Count of Burnett Wisconsin in determining whether to issue a permit. 1 m <br /> P 9 Y 9 $ $ <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.leprae top county offici Is charged with administering county ordinances or other authorized person to have n <br /> access to the above es 'bed premi at any reasonable time for the purpose of inspection. ` a <br /> SIGN HERE Rte Hw <br /> (a' re of owner ding contractor) (date) <br /> ZONING ADMINISTRATOR -++'t�� <br /> N <br /> TOWNSHIP PERMITS MAY BE REQUIRED \ �'^ g o o m <br /> 88 $ 8888vmi <br />