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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator C 0 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 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. m CD <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a O <br /> tions of the State of Wisconsin. o <br /> R J N N 1 <br /> 40 'e Imo/(�Q H lr S � �Y1. N <br /> O 0 <br /> OWNE (Please Print) Contractor or Surveyor or Agent m 4 <br /> i ads M;_( S _ M <br /> Address Address g <br /> I <br /> II.Q Lie,I h��,. ss,iz `o <br /> City,State,Zip ode City,State,Zip Code I <br /> I <br /> Telephone Telephone C <br /> Permits)Applied for: <br /> New Building FillinglGrading <br /> Addition Moving v <br /> Qk <br /> Sanitary ?C Camping Unit o o • <br /> Privy Subdivision 0 .`.- <br /> 0 O <br /> �I�7�j o <br /> Structure Use: ���- IU <br /> (family homelcabin, garage,addition,etc.) o v° j <br /> m <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. S <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, O <br /> river or stream, if applicable. <br /> 5. ft,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by n <br /> the owner. 6. Provide legal land description. 0 <br /> 0 <br /> PLOT PLAN 3 <br /> a y <br /> c <br /> 2 c <br /> z' a I <br /> lA O Irnp`•l <br /> � 1 <br /> /S <br /> y^i <br /> L <br /> I <br /> s <br /> 1 N <br /> r <br /> V O <br /> C <br /> 0 <br /> � 3 <br /> � a o <br /> Q� T <br /> Z Cj <br /> O <br /> Z <br /> 00 <br /> 1 <br /> 7J NN DDWm <br /> 0 C,= <br /> o d o o=3_ <br /> T O J m <br /> O O <br /> 0: <br /> i€ m <br /> 1 declare that this application (including an accompanyingschedule has been examined b me and to the best of m <br /> PP ( 9 Y ) Y ll <br /> knowledge and belief it is true,correct and complete.I acknowledge that lam responsible for the detail and accuracy of all i m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a O o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing u, <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> Q N <br /> SIGN HERE <br /> (si ure of owner r b 'Iding comer tractor) (date) o <br /> ZONING ADMINISTRATOR �:' ` o <br /> 1 s m <br /> TOWNSHIP PERMITS MAY BE REQUIRED R u m <br /> o � 000N <br />