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on cz-,mi), <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator <br /> - -�- APPLICATION FOR — LAND USE — PERMITS 3. <br /> a s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m n <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Buror, n� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0. V <br /> tions the State of Wisconsin. <br /> _ pf ic62 f eti �P l c <br /> OWNER(Please Print) Jll� Contractor or Surveyor or Agent °' (Af <br /> ?�3��� Lnrc6f-C11J jCll �j) <br /> Address a Address <br /> City,State,Zip CoCd7e/�� City, State,Zip Code C <br /> '!MX, <br /> ele hon n(i7 Telephone <br /> �3�� atnra�J TS.IJ , <br /> Emergency/Fire No. and Road Name ^ <br /> Legal Description(as indicated on tax statement) o y <br /> Permit(s)Applied for: 1:)e� O <br /> New Building SanitaryFilling/Grading Camping Unit 0 <br /> w 555 <br /> Addition �P/rivyv //Moving / a Z Subdivision 0 0 <br /> Structure Use: N <br /> �/ �C✓ `yn/ / �.51 v 1 <br /> o <br /> (family home/cabin,garage,type of addition,etc.) <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). <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. 0 o <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 o]�l <br /> the owner. O <br /> 0 <br /> PLOT PLAN 1;eL�Du) Ln Ky 3 <br /> p <br /> - — _ 2 c <br /> 0 n� <br /> 0 <br /> n Z <br /> i <br /> V <br /> 0 <br /> w � o <br /> —q o <br /> 0 <br /> Q` <br /> W n . <br /> V <br /> _ � t <br /> Z <br /> \ 0 <br /> O <br /> G <br /> M my cnr DDmy <br /> 00 c _.mm nac <br /> COYC�1'i'in9 1` m a� J—n m na 7m0 <br /> o < °ic0o33 <br /> O J m <br /> O J : <br /> TSN: <br /> m <br /> �CS :nr <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- =; •.� $ a m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ! :a c E O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 ' m 0 i 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 abov ascribed premises at any reasonable time for the purpose of inspection. E <br /> oH: <br /> SIGN HERE tZ� S.3 Tn a t" <br /> np: ' <br /> igna re of owner iI g con ractor) (date) E ? 0 E <br /> d 03 : m 2S <br /> ZONING ADMINISTRATOR g xg <br /> t' ;��dS T <br /> J N O N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED ulm m u,o o m <br /> 0000� o Cn <br />