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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator a o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> iu o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and OF <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula• o. <br /> tions of the State of Wisconsin. - p <br /> N Ol <br /> 60A* No�c�K <br /> OWNERPlease Print o. <br /> ( 1 t Contractor or Surveyor or Agent <br /> X31 U r PC2ke It �,14e 1RQCuA <br /> Address Address <br /> 1 <br /> City,State,Zip Code City,State,Zip Code <br /> �TI �- ( t' tjb� <br /> Telephone Telephone <br /> q3"10 tno4u � fteLl,keayc xl <br /> Emergency/Fire No. and oad Name O <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: $ <br /> New Building Sanitary Filling/Grading Camping Unit <br /> Addition Privy p Moving Subdivision <br /> Structure Use: \)0 $ <br /> Z <br /> 'o <br /> (family homelcabin, garage,type of addition, etc.) m <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 /> PLOT PLAN a N <br /> y o `v <br /> f oNJ ' <br /> N <br /> i <br /> N ^� <br /> J <br /> O <br /> 0 <br /> n> o <br /> � � Z <br /> of <br /> re xly <br /> -�-- Add,L7 ate/ m n;c O <br /> N o <br /> (1permi qq� ��15bA1'✓rOGt �I�� z <br /> 8: O : : C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o E E j y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 i G <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I n <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. I <br /> T <br /> N <br /> SIGN HERE- rs-g� <br /> �{e�igRV�tJuu,,�rr^e of ow or or b�di�nyg�contracto (date) <br /> ' �'• ` $ <br /> ZONING ADMINISTRATOR <br /> -n <br /> NNU1N o(NTM <br /> TOWNSHIP PERMITS MAY BE REQUIRED $8$888 vmi <br />