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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator _ 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and is <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- 3 a <br /> tions of the State of Wisconsin. ^ <br /> roc �IoteRCI�S <br /> N � <br /> OWNER(Please Print) Contractor or Surveyor or Agent a f <br /> �+ a C_ a <br /> Address Address <br /> ( t )rk 1.U'I S�1 `S S3 O <br /> City,State,Zip Code City,State,Zip Code CJ <br /> Telephone Telephone f' <br /> Emergency/Fire No. and Road Name O <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision a i~ <br /> v <br /> Structure Use: o ° <br /> a <br /> (family home/cabin, garage,addition,etc.) <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 lake, Q \/ <br /> river or stream, if applicable. .A <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated byO <br /> O <br /> the owner, ° <br /> on 3 <br /> PLOT PLAN c m <br /> 71 Z `c <br /> S <br /> 1110 <br /> 40 <br /> 0 <br /> �- <br /> m <br /> v � <br /> w <br /> Z <br /> f <br /> m m R M <br /> mCwo�; <br /> w 2 w o 321(4 <br /> m <br /> O � : <br /> � 1a.3s F�rrn / �11 �1i �. I � � y ( 3 ° j3 , [3 � �� N € " o <br /> declarethat this application(including any accompanying schedule)has been examined by me and to the best of my knowl- r g`o_: '^ <br /> ' ii <br /> mE E A <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible forthe detail and accuracy of all informs- <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 /� <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- (A; ? $-P 8 <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 reeasonable`time for the purpose of inspection. O^p f <br /> S 11�ll 1C \ l\vf _ o E ° E <br /> m 3 0 <br /> SIGN HERE <br /> si ure owner or in ontractor <br /> (sig <br /> g ) (date) o <br /> ZONING ADMINISTRATOR <br /> Tg <br /> o n <br /> TOWNSHIP PERMITS MAY BE REQUIRED {{��"�"` ooInn <br />