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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w - o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <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- m m <br /> nett County Land Use Ordinance,Sanitation Cade,and with all other applicable County Ordinances and the laws and regula- 3 a i <br /> tions of the State of Wisconsin. <br /> OWNER(Please Print) Contractor or Surveyor or Agent n f <br /> )3 ? <br /> Address Address J <br /> L�4 Cr osse r Gni' .'S46a1 I <br /> City,State,Zip Code City,State,Zip Code <br /> 9frff-/f3/ <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> _ l <br /> Permit(s)Applied for: / 0✓ o <br /> New Building Sanitary Filling/Grading Camping Unit � <br /> Addition Privy Moving Subdivision o <br /> Structure Use: p N r� �f`� L �� � 99 <br /> (family home/cabin, garage, addition,etc.) z <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). 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. <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, <br /> river or stream, if applicable. 21 r J <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. o <br /> 9 v v <br /> PLOT PLAN 7I Z c <br /> o a <br /> C Ci <br /> lal e� <br /> � V o <br /> N <br /> o lam/ <br /> m <br /> o � <br /> N <br /> Z <br /> 9 <br /> i <br /> M co-0 rp r'>DCoy <br /> m a� �am ';n7o <br /> Cw o'�3 <br /> Z w w o m _ <br /> p i <br /> G = m <br /> i12 i D <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- g` ' 9 <br /> PP ( 9 Y ) Y Y o om : 9 <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- g N? O <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- <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. E n^o <br /> SIGN HERE 7 Ag <br /> (signatufe of owner or building contractor) (Ate) o <br /> ZONING ADMINISTRATOR � � <br /> IA fR�IA�HM� <br /> N(NIIUO 5( :p OOm <br /> TOWNSHIP PERMITS MAY BE REQUIRED 888888 Sin <br />