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0 Cc,,) )C <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 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 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the Statf Wisconsin. <br /> People CG-/ Iy S//,0Nill6J/ c�n�CxcL0— <br /> o o� <br /> = o <br /> 0 <br /> OWNE�5R(Please Print) Contractor or SuIlveyor or Agent m <br /> Addresssl;) WS Address <br /> W <br /> City,State,Zip Code City, State, Zip Code <br /> Telephone Telephone a z <br /> Emergency/Fire Noand Road Name <br /> m� <br /> Qgy,({v -�oA-j QlNe- nKU <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`-- <br /> Addition Privy Moving / Subdivision 6 <br /> l�e�r o� L�ti' boat �5 tix IuA - I�y' LI-06h <br /> Structure use: U p <br /> (family homekiabin, garage, type of addition, etc.) <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. <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 /> 0 <br /> 3 <br /> PLOT PLAN a N <br /> Z c <br /> o v <br /> a <br /> te� <br /> rrV,, j0 <br /> � <br /> P <br /> ® ��� ti� P��f P��wCOCO <br /> N <br /> 0 0 <br /> o <br /> t �� T� �K�e 5�/ 0 o0 <br /> N jfe - � <br /> O <br /> I Z <br /> X <br /> mcm.mmoacmM <br /> 0 o< 330a= <br /> °cm5 E <br /> N z N O 3 0 <br /> N <br /> _ Y <br /> t(1 n 0 O <br /> 'no ' C <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 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- N= W c m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- E <br /> C I <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I fns <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- ji,. <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have I <br /> v; <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> T :N: <br /> O N: <br /> O <br /> SIGN HEREE <br /> gna r caner ding contractor) (date) o a o0 <br /> D O, <br /> ZONING ADMINISTRA O o n :moo <br /> O Q c, in j�i jS Rt IV N N � 1d <br /> TOWNSHIP PERMITS MAY BE REQUIRED �� v,u,o PR m <br /> .0 C)am <br /> 00000 OQ IA <br />