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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <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 �,}1 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 aa. <br /> (\ <br /> tions of the State of Wisconsin. o <br /> u d <br /> FL � ✓d �3 ,ascH <br /> O ERPI ase Print �- <br /> ( ) Contractor or Surveyor or Agent <br /> U.2 p y A 5 T <br /> Address Address <br /> V cit s/ 1U!_5 <br /> City, State,Zip Code City, State, Zip Code <br /> Telepho a Telephone <br /> /` ,n d -A-17 Z E 73t <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) / o <br /> Permit(s)Applied for: `j /i/Z A�F ��l po&, 1>O'" 4, <br /> l 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <- <br /> N <br /> Addition PrivyMoving Subdivision g <br /> v <br /> Structure Use: S rt/� z <br /> (family hom (cabin, garage, type of addition,etc.) m <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). <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. X1 <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. o <br /> PLOT PLAN a <br /> Z <br /> o T <br /> L 1 U1 E r <br /> i N <br /> AR ?7 I > <br /> I <br /> wP� <br /> DRtyC C13 � N <br /> u_ <br /> La <br /> .tf' ti <br /> yy� I{0'ISL ti <br /> I <br /> d� <br /> 34' <br /> -{{ <br /> I M (n-0(nr >>W -0 <br /> n Q< 3�oon- m <br /> am any <br /> �+ o 5i uCi '0 jn 3 <br /> o N N <br /> ye it 0 m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- O o: I 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 S-.^i c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i O G <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. 6)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. <br /> Q m <br /> SIGN HERE <br /> (sign ure of ow((n��er or build;ng ,c�oniractor) (date) i o I I o <br /> ZONING ADMINISTRATORH'N i o`: <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O V N <br /> T <br /> VtNtTO N <br /> O S 0 0 0 <br />