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0(\ cot y ) I_ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> ;v o <br /> TO THE ZONING ADM1P"STRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown bere�i.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- <br /> tions <br /> egula- 3 n <br /> tionso he State of Wisconsin. <br /> o <br /> N d <br /> n N <br /> C <br /> m nKiO <br /> OWNER se Print) Contractor or Surveyor or Agent n <br /> o <br /> m <br /> Address <br /> Address <br /> City, Stat City,State,Zip Code t <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: Lt <br /> o <br /> New Building Sanitary � Filling/Grading Camping Unit w <br /> Addition Privy Moving Subdivision o <br /> 6ie,9.3e #040 o7Lu <br /> Structure Use: - o � <br /> (family home/cabin, arage,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. <br /> 4.Show dimensions in feel 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 N <br /> Z Q <br /> o n <br /> m <br /> o Uf <br /> I <br /> l� 0 <br /> o <br /> 0 <br /> N � <br /> do21i`� <br /> II <br /> m c m m O a c <br /> n o ?n <br /> m <br /> LD. n an S <br /> m f z o f o <br /> Z o: 'i •z 1 <br /> cni ` S <br /> m <br /> u : n ' O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- p() o 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- — o 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 a <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. <br /> m <br /> SIGN HERE �`�� z1 /0j <br /> (signal f owner[¢��b��jdingg.�c�ontract�or)/ (date) o o <br /> ZONING ADMINISTRATOR 1 <br /> o: o <br /> NNON + Nm <br /> N(I�UtN OON <br /> TOWNSHIP PERMITS MAY BE REQUIRED c o 0 0 0 0 o m <br /> 0000000fA <br />