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0711 6(10�t' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d T o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 0 <br /> TO'7HE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and u, <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- mm <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. , m v I <br /> Iwll'llicol Che; iN Y y <br /> OWNER(Please Prin�t))/ ,l Contractor or Surveyor or Age <br /> n�7 a <br /> o <br /> l�Cr . t tl>il� CJ. �, 7-� d C� <br /> Adgre s _ Address <br /> City,Sta�lg,Zip ode City, Site,Zip Coe �-- <br /> Tele phgne ,, Telephone <br /> 41 <br /> Emergency/Fire No. and Road Name <br /> I Anal Dec_rrinr'nn fag indicated on tax statement) <br /> ao�e <br /> Permit(s)Applied for: n o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision <br /> M <br /> Structure Use: Z o <br /> ° � J <br /> (family home/cabin, garage, addition,etc.) <br /> 1. Show the location an s..a o all existing buildings(EB)and all new buildings(NB)and indicate North (N). o <br /> OF 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. Mill <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, 0 <br /> 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 0 0 <br /> the owner. <br /> 71v cn <br /> PLOT PLAN '1I Z v <br /> � o a <br /> tem <br /> C <br /> U) <br /> n <br /> 010 <br /> 00 <br /> a <br /> � z <br /> 1000, <br /> 33 0.0 DDOoy <br /> m cammnacm <br /> m n� .�--nm aa>D <br /> v ° C0 M8 <br /> H m O m <br /> € _ m <br /> of LIn p <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 informs- 5 m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- - H c H: O <br /> NON; <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit.1- ?m v': <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 O~o <br /> m m m <br /> m 3 0 <br /> to y,m rn: <br /> (signature of owner or bt{ilding contractor) (date) I o y g <br /> ZONING ADMINISTRATOR <br /> iA iA�'iA iAin is n <br /> TOWNSHIP PERMITS MAY BE REQUIRED NNO N-P Tm <br /> OO <br /> S89 009M <br />