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Burnett County 7410 Co. Rd. K, #1022 Siren, WI 54872 Office of Zoning Administrator on v -i Z <br /> APPLICATION FOR - LAND USE - PERMITS 3 <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 Bur- _ <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- m <br /> tions of the State off Wisconsin. <br /> , M d <br /> —94 CA <br /> OWNER(Please Print) m <br /> Contractor or Surveyor or Agent n £ <br /> Address Address '? ) <br /> 57- /QALt n/ S S�l c� 6- <br /> City,State Zip Code City,State,Zip Code <br /> I ) r2 �/,u <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building' Filling/Grading <br /> Addition <br /> Moving <br /> Sanitary <br /> Camping Unit <br /> Privy Subdivision o <br /> Structure Use: U l.� l )t�� I `�- Sfo� ,P� 5.��� � <br /> (family home/cabin, garage,additi n,etc.) Z O <br /> v <br /> Directions for plot plan drawing: o � <br /> a <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 drainfieltl(DF). <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. o <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 lake, <br /> river or stream, if applicable. <br /> 5. If,separate plaits alg subrPitted by an arcn!fact,engineer,builder,contractor,etc.,the plans must be signed and dated by ' <br /> the owner. 6 Provide legal land description. <br /> PLOT PLAN ,/. f l ff 3 ZII 41 <br /> c <br /> o a <br /> N. <br /> O <br /> J <br /> I \T <br /> • V p <br /> If <br /> P <br /> 1 N <br /> O TI Q_ <br /> 11 Q <br /> J <br /> Q 1�i <br /> J \i <br /> J <br /> m <br /> 0 <br /> N � <br /> T I^ <br /> m RJ <br /> Z <br /> 0 <br /> 1 Z <br /> ��11 � <br /> S}1U i m PaT; ot; 4397 <br /> �7 mv<nrDDp <br /> 0 or<Z 3 a m <br /> 9 N.: `Z N O j 9 <br /> O J <br /> rn <br /> Cc <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my ` ' <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all °i m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that A E m <br /> this information i am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a ` a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing g <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. 1 ` '^ <br /> T <br /> R <br /> SIGN HERE K2j�l� <br /> ature of owner or building contra tor) (date)/ 'L <br /> ZONING ADMINISTRATOR <br /> .drri <br /> TOWNSHIP PERMITS MAY BE REQUIRED C I ??1' y� I� UkkD ^ N o n`"m <br /> NPp "00V <br /> 08889ooai <br /> Drlue 41 r��=how or.w� �_ (pelju-S � <br />