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(6, r p <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0o o <br /> APPLICATION FOR — LAND USE — PERMITS3' <br /> d o <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 m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a ) <br /> ti of t e Stat of Wisco sin. m m <br /> ^ o <br /> OWNER Please Prie) / Contractor or Surveyor or Agent <br /> o. , <br /> Q�(3� ( [tr/1�F91rr� g � A °_ <br /> AddresyQ, ( �. �•l✓ 1 S L �3 A Ske}'C'w,"rJ 0I�:I I L J I J T 0 7 I <br /> City,St a e,ZZI Codq� ,7 City, State,Zip Code <br /> 7 <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for, �( o <br /> New Building X Sanitary ' ` Filling/Grading Camping Unit 0 <br /> u+ <br /> Addition PrivyMo�ving Subdivision or <br /> Structure Use: �^A� �`����'I� ^ '• 'Ir"• a <br /> (family home/cabin,Aarage, 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). �- rc <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. 11 <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 V, <br /> river or stream, if applicable. M .� <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 o <br /> the owner. <br /> 7Ia <br /> PLOT PLAN <br /> Itl IN � ym <br /> c <br /> r—• s <br /> I <br /> cn <br /> n O <br /> Ii = <br /> N T <br /> � T <br /> m f <br /> c + � <br /> w <br /> z <br /> f <br /> S p19N�DD0oy <br /> m c �.m nacm <br /> m g� �'nm an9 <br /> a wi � <br /> 2 p: Ni : 1 <br /> P TINE M <br /> =_' m <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowo im <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all inform E a; ? m <br /> tion contained in this application(Including any accompanying schedule)and I further declare that I recognize that this info rA$r O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this a Q ` E $-P $ <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. I Tt E: m^m <br /> 77 G 0 3 <br /> SIGN HE <br /> of � <br /> "�— <br /> (signa ur f owneiSir building contractor) �' (date) v E g <br /> ZONING ADMINISTRATOR <br /> win Nin inw <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O N + <br /> mrny�mo. � <br />