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n n Co`Y1, V <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITSd 3 <br /> � - 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- _9 <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. o <br /> f�V {�FIDMAI� y w <br /> o <br /> OWN leaase Print) �� Contractor or Surveyor or Agent n F <br /> �`l - ? <br /> WOW <br /> Address <br /> I�iK.EOW MN . 650 43 LA^� <br /> City,State,Zip Code City,State,Zip Code \_ <br /> ,L <br /> Telephone Telephone ) <br /> Emergency/Fire No.and Road Name G` <br /> Legal Description (as indicated on tax statement) � d <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary X Filling/Grading Camping Unit y ]S <br /> r <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: o 0 <br /> (family home/cabin, garage, type of addition,etc.) — <br /> 71. <br /> Directions for plot plan drawing: M <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. 0 <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- 0 <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. n (U? Y <br /> 0 <br /> 3 <br /> PLOT PLAN = C I�. <br /> Z V <br /> o n 1 �1 <br /> _ 5 <br /> �Lri S ° <br /> J <br /> N <br /> N a <br /> r o <br /> co <br /> 0 <br /> J <br /> 0 <br /> I <br /> J <br /> tp <br /> O <br /> N � <br /> { Z <br /> I� <br /> G <br /> c M.m d 0 a a m <br /> 0 a< J J 0 a_. m <br /> m n < =am =ny <br /> a <br /> w: S <br /> «[ m <br /> O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- C>o I y <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- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I a <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 /> m <br /> SIGN HERE <br /> ;(sigple of owner ding contractor) (date) o <br /> r� <br /> ZONING ADMINISTRATOR t/ g <br /> n T <br /> TOWNSHIP PERMITS MAY BE REQUIRED `" v, o 0o p m <br /> o' 0 00 <br /> do 0 000YA <br />