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0n C "� (y) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> 0 <br /> TOTHE ZONING'ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 6 <br /> located as,shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tioAs of the State of Wisconsin. m o J <br /> u1c csChtka.In4 �Prl tJ n J F <br /> O ti- c <br /> OWN�B ((Please Print) Contractor or Surveyor or Age n £ <br /> e2te'IDSi-��-tJ4 �. - 1�•D . �X 1I a � <br /> Addre s T Addss m <br /> Cly <br /> Z'Irra- lV! 51483 MOOV\,e1( <br /> Cit ,State,Zip Code City, S ate,Zip Code r '� <br /> 35 - 4I q 71 s - �aS <br /> Telephone Telephone n <br /> a�Qo�4- +leu � <br /> Emergency/Fire No.and Road Name d, <br /> Legal Description(as indicated on tax statement) o <br /> PermitKApplied for: o (l <br /> New Building Sanitary _ Filling/Grading Camping Unit 0 <br /> m � . <br /> Addition Privy Moving Subdivision g 0 i <br /> v � <br /> Structure Use: o <br /> o � <br /> (fam ly home/cabin,garage,addition,etc.) <br /> 7 <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). Q/ o <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. 11 <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, C <br /> river or stream, if applicable. IX <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by 10 O <br /> the owner. o <br /> 71 ,o N <br /> PLOT PLAN 'll z cv <br /> o a <br /> m � <br /> orcA M m o <br /> C, I(✓9 <br /> C, <br /> V <br /> r` m <br /> ' e <br /> 0 <br /> I� <br /> N <br /> If <br /> m <br /> o � <br /> I <br /> Z <br /> 9 <br /> I \ <br /> U J <br /> 2 C M m r n p ca-0 <br /> io iii '--nm nnS <br /> w E m0 63 ic <br /> oCn <br /> �m <br /> m <br /> a)n O <br /> Ogi € C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- EL o : m m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- j <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue <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.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to he above described premises t any reasonable time for the purpose of inspection. i I O^o <br /> m m 0 <br /> N V Nx' <br /> � . .,J (�� 118190 »m <br /> SIGN HERE m o: E <br /> (signatur o wner b ' ing contrac r (date) �:C o' o <br /> ZONING ADMINISTRATOR <br /> ��Hj� �HrAm <br /> TOWNS IP PERMITS MAY BE REQUIREDu�P oo�m <br /> X88 888ai <br />