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yl <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'a a 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 'z w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the But- <br /> CD C <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. v <br /> c C Lo�kwoo al �c � �- mAr <br /> OWNE (Please Print) Contractor or Surveyor or Agent n F <br /> A ;a Address m <br /> iii-clic P. s`5—o1 <br /> City, a <br /> Stte,Zip Co City,State,Zip Code <br /> l - biz 7y _ 9�� � <br /> Telephone Telephone <br /> 4io .2 -7 — Green- r-6 S <br /> Emergency/Fire No.and Road Name <br /> Legal Description(as indicated on tax statement) <br /> v <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> _ <br /> m <br /> Addition Privy Moving Subdivision <br /> Structure Use: AV 1 artt. )Oov ST r an'e L o v <br /> (family home/cabin garage,addition,etc.) z <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). r <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, <br /> river or stream, if applicable. ,A <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by O <br /> the owner. <br /> 3 <br /> PLOT PLAN an v ur <br /> Z c <br /> Rea � o a <br /> m o <br /> w � <br /> M _ <br /> l 'T\—sr 4P�osc, l3 � � i <br /> yQ x �o � J 0 <br /> prleqFte <br /> u <br /> for c <br /> FL <br /> m <br /> ! FL <br /> 9' Shead He us e. Ile 3 <br /> I <br /> � wvu,�sam� <br /> C D <br /> Gak � _ , rj) „ <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- <br /> tion contained in this application(Including any accompanying schedule)and I further declare that I recognize that this infor- y�g w p <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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- $a $I <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 0. <br /> o <br /> m ' 3 0 <br /> SIGN HERE <br /> gn uie of 0 or building contractor) (date) o i <br /> ZONING ADMINISTRATO9116 <br /> TOWNSHIP ERMITS MAY BE REQUIRED NNNN O00 <br /> 8888$$$rma <br />