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Burnett-County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator ( M -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> o <br /> TO THE TONING 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 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. p <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> 1z, 6H \ � L <br /> AdTess s S Address <br /> �+ <br /> City, tati,e,Zip Cod <br /> City,State,Zip Code <br /> I <br /> -���-a3g 1 <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> New Building Filling/Grading G� <br /> Addition Moving o <br /> Sanitary Camping Unit o <br /> Privy Subdivision 0 <br /> r <br /> o � <br /> Structure Use: M <br /> (family homelcabin, garage,addition,etc.) o v° <br /> 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). <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 <br /> the owner. 6. Provide legal land description. 0 <br /> PLOT PLAN � 3 m' <br /> P Q <br /> o a <br /> 5 I <br /> O <br /> I 3 � <br /> � `CCnn <br /> Z <br /> cl u <br /> o' <br /> IV <br /> O <br /> 0 <br /> 7 <br /> b <br /> H y <br /> n <br /> Z <br /> m IIII/rC <br /> Z <br /> 0 <br /> :6 <br /> Z <br /> 11^)V) D <br /> I <br /> �. <br /> N M(nrD m <br /> m c <.mmn c <br /> n a< 7 p p <br /> m a� nm »n_ <br /> Cow <br /> 0 p <br /> m <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m o c C <br /> PP ( 9 Y ) Y Y — o E m y <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of allm <br /> /t <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing (A [ ; � <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> D <br /> N <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) 'v N <br /> o: o <br /> ZONING ADMINISTRATOR o o <br /> o: o <br /> fn�1 <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N$N o o N m <br /> 0000000tm/l <br />