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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> u o <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- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. — <br /> N � <br /> ✓A� /j1Gl7�Z fA�Y/E <br /> io o <br /> OWNER(Please Print) Contractor or Surveyor or Agent ° 3E <br /> 1?t`o� 3�ruCLELy �i w � m <br /> Address / Address = I O <br /> .51--Y'gcl— yid - <br /> City,State,Zip Code City,State,Zip Code V 1 <br /> Telephone Telephone <br /> O'7�7 kel��Jr� rcu/v'(' <br /> Emergen�ylpire No.And Road Name 0 <br /> �"Noi; j!a+.L <br /> Legal Description(as indicated on tax statement) ry o <br /> Permit(s)Applied for: x C a o i <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`.- <br /> v+ r <br /> Addition Privy Moving Subdivision 0 o <br /> v <br /> z a <br /> Structure Use: ° 'm <br /> (family homelcabin,garage,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). o <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 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. 3 <br /> PLOT PLAN z `v <br /> � o a <br /> A "s: <br /> m o <br /> m n s <br /> 3 �c <br /> ' s <br /> , m <br /> J <br /> O —� <br /> N <br /> o <br /> I� <br /> Ic <br /> Z <br /> 9 <br /> C4e—. I39 <br /> ,D}rI V r <br /> 5,�bacjZ 6K. b r,A _arq <br /> m <br /> m n� :nmaaa <br /> ��:"�'.c."{ C�Z•e��. ��Z-17��ws�dy�j o ` °' c w o 3 3 <br /> wi dmo �ao _ <br /> —r: =2s i m <br /> I declare that this application(including any accompanying schedule)has been examined by me an 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- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Yt N; G <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 <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 /> "x <br /> SIGN HERE I '• <br /> ign ure ofo e or b i n actor) (date( <br /> ZONING ADMINISTRATOR <br /> (� NNr N_W <br /> TOW SHIP PERMITS MAY BE REQUIRED <br /> 8$ 88$x$ <br />