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on CGOA(' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> a 's <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � m <br /> J <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- ° �J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n p <br /> tions of the State of Wisconsin. <br /> 'o <br /> N d <br /> J kv olG k 'r,,k6 d� o <br /> OWNER(Please Print) Contractor or Surveyor or Agent a £ <br /> CCk d <br /> m � <br /> Address r Address <br /> Cit State,Zip Code City, State,Zip Code t <br /> Telephone Telephone I <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) y <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary FillinglGrading Camping Unit <br /> Addition Privy Moving Subdivision o <br /> (� <br /> v <br /> Structure Use: <br /> (family home/cabin, garage, type of addition, etc.) <br /> Directions for plot plan drawing: <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 drainfield (DF). U <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream -if within 300 ft. UI <br /> 4.Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to ordi- S. <br /> nary high water mark of lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. o <br /> 3 <br /> PLOT PLAN Z <br /> 0 o IZ <br /> n <br /> O <br /> y <br /> N <br /> L <br /> a <br /> 0 c 0 <br /> N <br /> 0 <br /> U' <br /> w � <br /> r. I� <br /> z <br /> I� <br /> m anm anA <br /> o' mcmo� 3 <br /> Q w O 7 m <br /> �10 : x <br /> «: � , :� m <br /> ljlp� <br /> O: :gyp;• C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o I I�10 :cl S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- ; 8 c G <br /> tion 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. I ! a <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 /> "cation.I agree to permit county officials charged with administering county ordinances or other authorized person to have E o+v <br /> -s to the ab ascribed premises at any reasonable time for the purpose of inspection. "4AI <br /> 1V: ' <br /> y�y fA t :l7n <br /> (signaturg7of owner or building contractor) (date) O ;o c;a; E0. <br /> i0: oini o <br /> Es <br /> -OR d <br /> 0 0 ooMfA <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br />