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o f A (-c31f)-f- <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n c� <br /> tiTf the State of{Wisconsin. — <br /> tc:A)hyYNOUJ`)) -Ro r <br /> w 0 <br /> OWNER(Pte se Print) R� Contractor or Surveyor or Agent a <br /> � <br /> I <br /> Ad s Address <br /> 11 (iI Le Wf - s LI-7� G U) O_ <br /> City, State,Zip Code —� �� City, State, Zip Code i t � <br /> Telephone Telephone O <br /> Emergency/Fire No. and Road Name C� <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: o ° <br /> (family home/cabin, garage, type of addition,etc.) — <br /> r <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). �N <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). �f <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. In <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- <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 0 <br /> PLOT PLAN v N <br /> Z c <br /> O y Q <br /> 0. <br /> / N <br /> N <br /> r <br /> bQ. �rV�.iJV QG <br /> �0�e <br /> 4 <br /> s�.t Gry Vj N <br /> N <br /> 0 <br /> N � <br /> Z <br /> ` /O',`C� M C =.0 0 D a m m <br /> G�'X- � C m c 0.w w 0 n c m <br /> n o-< oc 0a= <br /> COI(?, 07tlw .�i m n� - n 0 <br /> �s n¢ �fi K ler <br /> 64 ` Gt(+Jm — //�s 9 y z 0 o ` M 3 <br /> pm e 1� Z p'; a : 1 <br /> 9 Qp( Lrlarl�. ° Z C' 70 <br /> zf m <br /> c0 O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- o? m <br /> tion contained in this application(including an accompanying schedule and I further declare that I recognize that this infor- _C o I G <br /> PP C 9 Y P 9 ) 9 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue apermit. <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 the abov scribed premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> w <br /> SIGN HERE <br /> (sign e o owner or uil ontractor) (d e) o o <br /> ZONING ADMINISTRATOR V N <br /> v NNO N <br /> TOWNSHIP PERMITS MAY BE REQUIRED d o 0 0 o o m <br /> 00o goo Vl <br />