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0�\ Com f <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <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 y <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 /> tions of the State of Wisconsin. A // m m <br /> L—) itV N Y S •-/-- 6 Rf l wayne.Eirq <br /> J c <br /> O <br /> OWNE (Please Print) Contractor or Surveyor or Agent n H <br /> -0!k- '3 T' d '7 lo <br /> Addressi Address <br /> D ce /, f <br /> City,State,Zip Coe City, State,Zip Code i .o <br /> Telephone Telephone 1 <br /> t^ <br /> Emergency/Fire No.and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: 0 G) <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit w »' <br /> r <br /> AdditionPrivy Moving Subdivision o ° <br /> v <br /> Structure Use: }---Q(q <br /> 0 <br /> (fatily home/cabin, garage, type of addition,etc.) <br /> W � <br /> Directions for plot plan drawing: .0 <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings(NS)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 (n <br /> the owner. n <br /> 0 <br /> 3 <br /> PLOT PLAN a N <br /> Z = <br /> n k) <br /> N <br /> O <br /> O C a <br /> S<l <br /> N <br /> a. <br /> �s <br /> a <br /> N ' h <br /> 0 <br /> N � <br /> H `n <br /> Z <br /> C <br /> c mrn acmm <br /> 0 0` 0 a-. m <br /> S a - O =;am <br /> -R 5 ° yon ; <br /> N O MQ <br /> Z O Z : <br /> O O 'i i <br /> �[ m <br /> Ccf O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- n m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. g <br /> o <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I : a : E <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 /> m <br /> SIGN HERE _E <br /> igna�tu�re/��o,f,,owns r�Q!r bGuild�ing contractpr) (date) o o <br /> ZONING ADMINISTRATOR <br /> �� 4�� <br /> � T <br /> iJNON ��N m <br /> TOWNSHIP PERMITS MAY BE REQUIREDU ° m <br /> b000000 <br /> 0000000M <br />