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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratory M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0- <br /> tions of the State of Wisconsin. y <br /> OWNER(Please Print) Contractor or Surveyor or Agent _ n f <br /> 12-0c,(, T44t4✓?lC 'JLri �Lfi91 K m <br /> Address Address <br /> City, State, Zip Code lJ� � ��`� LA-:1+ �7'1 �� City,State,Zip Code IT <br /> 7i --)` •3n•?, l Gil._ 5 <br /> Telephone Telephone <br /> ayi�,C, - l:r� '�- t�(='z=.; I�,��i+T✓-_'t4r�c::,,4`I - � <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: o <br /> New Building ,4— Sanitary Filling/Grading Camping Unit H <br /> r <br /> Addition Privy "Iing Subdivision o ° <br /> as Z <br /> Structure Use: C'T�{n 11 4- � (• o v <br /> (family home/cabin, garage, type of addition,etc.) <br /> r <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). <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 <br /> the owner. o <br /> 3 <br /> PLOT PLAN C� Z C <br /> Yt o Cr <br /> 10 <br /> t 3 � <br /> .. <br /> ap ( Lt <br /> 0 <br /> �rz2' <br /> j �— <br /> 1 au/ <br /> l••�� Ik�V x: (U f'>IAC.k=Cti,� l-.,uC �� <br /> i n <br /> dcc, 6.AQ',A4L <br /> lU <br /> C M.W00 m m c m m o c <br /> �y <br /> o a m 3, <br /> i <br /> o _ °0 w o= <br /> ' Z O p N <br /> e 0i A <br /> s : . <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 informa- o 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 /> T <br /> SIGN HERE ( <br /> sivgre of owner b ilding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> �1 <br /> ` IV NOV QN <br /> TOWNSHIP PERMITS MAY BE REQUIRED " c o `n <br /> one o <br /> 000e <br /> 00 <br />