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7410 Co. Rd. K, 1102 <br /> Siren, 1 54872 <br /> Burnett County Office of Zoning Administrator C o z <br /> APPLICATION FOR — LAND USE — PERMITS 3 _ 9> <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� m o <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. o <br /> 53 <br /> n F C, <br /> OWN R((P_lease Print)/ Contractor or Surveyor or Agent o J <br /> , ox 31 7 d m <br /> Addr ss Address ( GI <br /> � ,—Rom /hr� SSD} o <br /> City, State, ip Code City, State,Zip Code G <br /> �al� <br /> Telephone Telephone <br /> Permits)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit _ <br /> Privy Subdivision <br /> o < <br /> J <br /> Structure Use: 1111 (l�b Jfo/ t 1,;" L NC 14 5 0 <br /> v <br /> (family home/cabin,garage, addition, etc.) o a <br /> M <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). <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. <br /> 0- <br /> 4. Show dimensions in feet of the following:(-building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> river or stream, if applicable. r„ <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by 3 <br /> the owner. <br /> PLOT PLAN a ego escrip ion on a side o is for as on ax s a emen 3 ` <br /> �r -P m0 <br /> �Rop�RT� P y°Q <br /> p wF w9 6R y �', RC ►� <br /> � �RKE I`flK� T1 910 <br /> 0 � <br /> 0 _ co <br /> 7. <br /> _J O <br /> IN <br /> o <br /> J <br /> O <br /> 2 <br /> �w� s <br /> z <br /> I It <br /> o <br /> QRop£ R-V P Z <br /> Nil <br /> OLtT�-\OWSL <br /> Dco-0 <br /> 3 . ��C� m a`c rJan an7o <br /> a < : m c o 3; <br /> Z N : J <br /> O O 1 <br /> J N: ; A <br /> di m <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m <br /> PP ( 9 Y ) Y Y S: <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all <br /> information contained in this application(including an accompanyingschedule and I furtherdeclare that I recognize that <br /> PP (� 9 Y ) 9 i O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <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. <br /> T <br /> N <br /> SIGN HERE d' <br /> (sign re o owner or bu' contract ) (date) �( o o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS AY BE REQUIRED Nm <br /> X00 o)o88pm1 <br /> i <br />