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0(-� c() M 19- <br /> Burnett <br /> Burnett C, /410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0m o 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 � H <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c R <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a `V <br /> tions of the State of Wisconsin. ^ �e /I y o <br /> OWNER(Please gint) 1 O Contractor or SurAyor or Agent o f <br /> w VI m <br /> Address A � (� `I Address -3 Y_:3'3 <br /> City,State,Zip Co City,Stat�ce,Y�Zip Code .� <br /> � SI OI <br /> Telephone Telephone — <br /> EmergencylFire No.and Road Name LJ <br /> Legal Description(as indicated on tax statement) a <br /> Permit(s)Applied for. n o <br /> New Building Sanitary Filling/Grading Camping Unit 3 <br /> w <br /> Addition Privy Moving Subdivision <br /> v <br /> Zo <br /> Structure Use: P o <br /> (family home/cabin, garage,addition,etc.) C <br /> Directions for plot plan drawing: G <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). op r' <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 lake, C <br /> river or stream, If applicable. M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by O <br /> the owner. <br /> on 3 N <br /> PLOT PLAN -�(9� %R cNt�yj o <br /> m <br /> cU <br /> U0 � I <br /> I ca <br /> N = <br /> 0 <br /> N <br /> m � <br /> o � <br /> k <br /> F <br /> D <br /> I <br /> r– <br /> � rA�m[DDOo9 <br /> w c �.m oncm <br /> U w ;zW o �eo � <br /> gni rn <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the bestof my knowl <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- «+ G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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- iE $n <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. E O..o <br /> w w : <br /> Sw . 9NF. <br /> SIGN HERE <br /> (sighilje of o building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> QNN ONB9H(p-n <br /> TOWNSHIP PERMITS MAY BE REQUIRED a v v o o$m <br />