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011 ca m v <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 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 m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m Q <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a j <br /> tions of the State of Wisconsin. rz37 <br /> o �J <br /> Skuhe.s <br /> OWNER(Please Print) Contractor or Surveyor or Agent n £O <br /> xt637 6, uelana( CrCS +_ d <br /> Address Address m <br /> ColuMbo'a Ne;ltits, Mki S-Ss11a1 N <br /> City,State,Zip Code City,State,Zip Code <br /> (.iL - S71 - loo - I <br /> Telephone �. Telephone O <br /> a9 065- So. ,Jo %In5oA L4ke 12ooLj <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: L7 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> H ro <br /> Addition Privy vMoving Subdivision S <br /> O <br /> Gn)2 R GE Z <br /> Structure Use: ° � r <br /> (family home/cabin, garage,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). 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, Q <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 byO <br /> O <br /> the owner. 0 <br /> PLOT PLAN 7I z a <br /> M <br /> o a <br /> Seg A�� � <br /> a 's <br /> M <br /> u <br /> 0 <br /> 6 <br /> r <br /> m <br /> n <br /> d <br /> O I� <br /> m � <br /> o <br /> V"(fl <br /> N <br /> Z <br /> f S <br /> r <br /> m c ammnnc�m <br /> o < 01Cwo�3 <br /> 42 <br /> C' <br /> z o E : , Q : i 1 <br /> P " j mN: [ S <br /> n =2 m <br /> c'o € D <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of 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 informs- 0--j >, m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- S'A: O <br /> mation I am providing will be relied upon b the Count of Burnett Wisconsin in determining whether to issue a permit. 1 cy N <br /> P 9 P Y Y 9 P <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. E n~ <br /> T N <br /> N <br /> SIGN HERE r (o <br /> (s7rffe of owner or u'ding contractor) (date) o j <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED PIPrn o o'o m <br /> $8g000$fA <br />