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L;T� cc)r_K ' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o a <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 'z w <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 a <br /> tions sof the State of Wisconsin. e7 ter' <br /> m <br /> n O <br /> OWN R(Please Print) Contractor or Surveyor or Agent E <br /> Address Addres m I <br /> STygy�"yIG L� �9 559 7�� UfI!/ �, 1� <br /> City,State,Zip Code City,State,Zip Code \ I <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> 7 <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for. –� <br /> New BuildingO <br /> —�_ Sanitary �� Filling/Grading rading Camping Unit <br /> w <br /> AdditionPrivy Moving Subdivision S <br /> n <br /> Structure Use: eji WP'iy 1 i N6 + <br /> (family home/cabin, garage, addition,etc.) W z <br /> Directions for plot plan drawing: J <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). o <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, �.. <br /> 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 O <br /> the owner. <br /> 71 ,o m <br /> PLOT PLAN 11 Z v <br /> o a <br /> C Ii <br /> m � <br /> ( 7 <br /> 0 <br /> N <br /> Std Kz I(/( aw(,, m \' <br /> o <br /> Z <br /> / D <br /> �Se$4 nK- <br /> i <br /> emil Q 1� O � — te-I, I h �u[GUCC� s for CA >>w m <br /> � b�(� u'r"" _ m4 ani <br /> w O � <br /> w Zw O �4m <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> edge <br /> g` '• n ' C <br /> PP ( 9 Y ) Y Y y <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all infor na- <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 <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- - ; $a $ <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have \I <br /> access to the above described premises at any reasonable time for the purpose of inspection. 1 ` I O~o <br /> SIGN HERE H ` �•m g <br /> (signkure of owner or ding bontractoo (date i o <br /> ZONING ADMINISTRATOR <br /> �a Hin� <br /> TOWNSHIP PERMITS MAY BE REQUIRED o <br /> 888 <br />