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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 'a --I 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d a <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- mm <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0- <br /> tions of the State of Wisconsin. <br /> /1 w o <br /> ©,6E',pT G, V011Lf4le7-H <br /> a O <br /> OWNER(Please Print) Contractor or Surveyor or Agent F <br /> 33/4 DHeiv DRivE _ <br /> Address Address `� Q <br /> 1,0C.'ss r,-R GG isc _ ) <br /> City,State,Zip Code City, State,Zip Code <br /> 7/.s-866- 8472 0/,z 61Z-53S- 76¢7 <br /> Telephone Telephone <br /> SAME <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit H D j <br /> �1 <br /> Addition Privy Moving n Subdivis'ronL o <br /> Q� LA)IT �Y11/LSI kQi3Yl� GVe I l o <br /> Structure Use: o <br /> (family home/cabin, gars e,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). o <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 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. <br /> 0 <br /> 3 <br /> PLOT PLAN N <br /> Z c <br /> 0 Cr <br /> 5 <br /> N <br /> G10 O <br /> f s <br /> I <br /> D <br /> y <br /> t 9� <br /> 0 <br /> N I l <br /> J 1 <br /> I� <br /> O <br /> Z <br /> D <br /> M c�mmc>>M -0 <br /> w2 w 0 0 <br /> Z ? � � i : 1 <br /> ,,,, � N : m <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' G <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. 1 n [ <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 /> 17m <br /> SIGN HERE "� `KL <br /> (sl cure o wner or ildin contractor) (date) o o <br /> ZONING ADMINISTRATOR ` o= <br /> _ T <br /> N N O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 000000 <br /> 0 0 0 0 0 0 y <br />