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OMB COMPUTER/SCANNED r ,co <br /> .orneii# County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y `) <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the mCD <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 Wisconsin. _ N <br /> c �? <br /> f�� A X1 1 U l,[�A LC/() a f <br /> OWNER(Please Print) Contractor or Surveyor or Agent, v <br /> Address Address <br /> 0 /Z /yy - '5--S /ZJ TU e 1—.4L ZA K,E,d!/i ( 4-L � <br /> City, State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> LA <br /> Legal Description (as indicated on tax statement) <br /> :11 C 1;Y !'�- V /1G p o <br /> Pe it(s)Applied for: �1&�Cz'gs o -_ <br /> Dwelling Z Addition Filling/Grading Camping Unit 6 <br /> o 1 <br /> Accessory Building Sanitary Privy Subdivision t ° m <br /> Garage �� j <br /> Structure Use: i P,Iv I 1 <-' _ �-L- <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X ` <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 drainfield (DF). 3 <br /> cn <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 Cr <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 N <br /> dated by the owner. m <br /> C <br /> PLOT LA <br /> I <br /> 01� Q (n <br /> 0 <br /> 9 <br /> f <br /> o <br /> 1 <br /> �2 � e Sld <br /> z <br /> 2-6 <br /> I <br /> f�D o c -T U., y D a 0 <br /> m - or•< 2' a (D a r <br /> 2a <br /> iv <br /> N <br /> 17,'S � fJ : T �n <br /> 8 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- v+ m 9 t <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 'w v, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 `,0° 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- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have c, <br /> access to the above described premises at any reasonable time for the purpose of inspection. w g o <br /> 0 : <br /> A 0 AA N <br /> SIGN HERE <br /> (signature of owner o building contrac or) - lat ) o ;,: <br /> ZONING ADMINISTRATOR g <br /> I ' ��� -_ 2 <br /> . - , ' d►v► -�to V► (fg71 I <br /> TOWNSHIP PERMITS MAY BE REQUIRED( I -Ln f-" !-n can Lnn o O <br /> {fiu ____ 888888 8 <br />