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Burnett Cmurky 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator /m ��o <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 'z io 0 <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 n <br /> tions of the State of Wisconsin - o <br /> %� i <br /> COPaLl� ZH'l'lnf neL �Gt�a kSCrY\ � m <br /> OWNER(Please Print) m O <br /> Contractor or r Age A a� <br /> a 13 n. YYla10 11 l� 7 <br /> m <br /> Ad ress Address m <br /> R-m i? Imo l C4 i Z" . (,-:1-3 za �nd n e1r (�J .54 KOCity,State,Zip Code City,S�Zip Code <br /> _ a?IZ- 543 -1 397 —�Iti -L,3ti-?4gZ ( O <br /> Telephone wig <br /> a � Telephone r r CT <br /> �O lJl t <br /> Emergency/Fire No.and Road Name ft <br /> Legal Description(as indicated on tax statement) <br /> 0 <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit o 4 <br /> Z <br /> Addition Privy Moving Subdivision o <br /> Structure Use: IT��'k-// 4�h'l,� z a <br /> P <br /> ° <br /> m <br /> (family/home/cabin,garage,addition,etc.) <br /> Directions for plot plan drawing: W <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). r- <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 lake, <br /> river or stream, if applicable. ,A <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. C O <br /> PLOT PLAN on p m <br /> L7 o a <br /> m o <br /> m � <br /> Su <br /> I y <br /> O <br /> 7 <br /> O <br /> 0 <br /> m <br /> O � <br /> u <br /> 0 <br /> Z <br /> >7 <br /> 11 p1v�N�D D07y <br /> m i£� am nay <br /> wi <br /> O mCo moo' ; <br /> Z i i m 1 <br /> O > . <br /> Tali i y <br /> hi <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 informa- <br /> tion contained In this application(including any accompanying schedule)and I further declare that I recognize that this infor- ' p <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <br /> �J! ` a P E <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- ,'• $. 8 <br /> plication.I agree to permit county officialsAparged with administering county ordinances or other authorized person to have <br /> access to the above described premises ft.Any reasonable time for the purpose of inspection. ? O o <br /> 'n m <br /> SIGN HERE <br /> (sign t o of owner ildin contractor) (date) o w g <br /> ZONING ADMINISTRATOR ` $' <br /> tnHyH�Hy+In <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED ON P."�o075 <br /> $$888$$vmi <br />