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Burnett County 7410 Co. Rd: K, No. 102, Siren, WI 54872 Office of Zoning Administrator u -a o c <br /> APPLICATION FOR — LAND USE — PERMITS <br /> s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m WE <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wis nein. m o (J <br /> N � <br /> OW R(Please Print �y..,� a O <br /> Contractor or Surveyor or ant n E <br /> N <br /> A rasa _ Addressdif <br /> �^" ✓ N <br /> ty,State,ZIP Code City,State,Zip Code <br /> Telephone Telephone <br /> a <br /> Emer ncylFire No.and Road Name <br /> z.. (/7 't /& L i <br /> Legal Description(as Indic ted on tax statement) o / <br /> Permit(s)Applied for. c <br /> New Building Sanitary FIIIInglGrading Camping Unit m <br /> Addition Privy Moving Subdivision 0 } <br /> Structure Use: .VOc9y �� � � D <br /> (family homelcabm,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). <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 f t 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 appll able. 31 <br /> 5. If,separate plans are a bmitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 <br /> the owner. <br /> PLOT PLAN c g <br /> �n <br /> /moi 0 <br /> NY <br /> rj J <br /> r•J <br /> 7 Z <br /> wee® <br /> ,e_ <br /> ='= Rnmv <br /> m <br /> o $4 »nm »_n9 <br /> - '�Q C O� <br /> _. Z Vii wa 70 . <br /> C o f E m.Z i i '4 <br /> _ 21 se i 21 <br /> =n <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- �=i `• i m <br /> tion contained In this application(including any accompanying schedule)and I further declare that I recognize that this infor- - ` fl N O <br /> motion 1 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- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the abov&described premises atany reasonable time for the purpose of inspection. c>~ <br /> SIGN HERE c - �'.Z Lt <br /> (s' nat re of owner o u' Ing contractor) (date) ` o[ <br /> ZONING ADMIN RATOR y,w_; '• <br /> TOWNSHIP PERMITS MAY BE REQUIRED v m <br />