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C7r l COp( <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� o o <br /> APPLICATION FOR — LAND USE — PERMITS W 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- 3 n <br /> tions of the State of Wisconsin. c ' n <br /> G /aR �y ��/eOiP / D. DUrvc�/✓ C /v . i '� <br /> a O <br /> OWNER(Please Print) �x Contractor or Surveyor or Agent o S <br /> ? <br /> Address Address <br /> 7e N /r✓ S/F2 Ctijr' <br /> City,State,Zip Code City, State,Zip Code I <br /> Fb-r- -5'2 <br /> Telephone Telephone o <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: <br /> / 0 <br /> New Building v Sanitary FillinglGrading Camping Unit y = '(� <br /> Addition Privy Moving Subdivision o <br /> 4 r <br /> Structure Use: C' -A6F -` I X36 / Y&ya o R <br /> (family homelcabin, 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(NS)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 /> 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 <br /> PLOT PLAN P <br /> o v <br /> W Q a <br /> rel N <br /> 1-01 <br /> Gni, <br /> 0 <br /> 3E c� <br /> m <br /> 0 <br /> N ri <br /> n <br /> y <br /> 4aT G <br /> u�� 4 p <br /> m c�mm aaCm <br /> m <br /> O 3 n <br /> z 0E <br /> d: 2 : " p <br /> : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- Q o :no p_E :•, E y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- Sao m <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 if� <br /> P Y Y Yrelying P g P- <br /> further accept liability which may be a result of the Count of Burnett on this information I am providing in this a <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m N: <br /> SIGN HERE :ol <br /> m 'o: d, <br /> (sig atu of own uilding contractor) (date) 0 3 0 <br /> ZONING ADMINISTRATOR <br /> T <br /> �NNOM8—m 1't <br /> TOWNSHIP PERMITS MAY BE REQUIRED Qo c o o c o m <br /> 000000 N <br />