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Burnett County.741Q,Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator �T �� 1Z <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> s <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- <br /> CD c <br /> CD <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> ti <br /> n oofft/f}�e/$tate of Wis opsin o R. <br /> O NF�R 3 �(Pleas PrinUContractor or Surveyor or Agent a E <br /> a <br /> AddrP� p Rt <br /> Address �- <br /> c���-'f�L\ tO <br /> 72-- <br /> City,State,Zip Code City,State,Zip Code <br /> �a� - aasa- <br /> Telephone ect Telephone <br /> `t�3� as„ 9i <br /> Emergency/Fire No.and Road-Name <br /> Legal Description(as indicated on tax statement) v <br /> Permit(s)Applied for. G7 <br /> New Building Sanitary Filling/Grading Camping Unit 6 <br /> m <br /> Addition Privy Moving Subdivision B <br /> 0 <br /> Structure Use: I o <br /> 'o <br /> (fam y 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). Q r <br /> 2. Show the location of the well (W), ( <br /> tank septic S o <br /> p T),and drainfield (DF). ( Q <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. M11 <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, 0 <br /> river or stream, if applicable. 9 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 3 <br /> the owner. <br /> PLOT PLAN an <br /> v m <br /> 71 Z `v <br /> O m <br /> Cn <br /> m 9� <br /> fi <br /> m <br /> 0 <br /> 2.o <br /> m <br /> o <br /> w <br /> I w Z <br /> z <br /> m c�eyi rtDi ac°� <br /> m c R:nnn-•m <br /> 9 wi 14CiE <br /> n =2i In <br /> O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g, m ? E S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ��-' ' <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I 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 jo permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the ab ve described remises at any reasonable time for the purpose of inspection. 0»o <br /> SIGN HERE / 9-1 <br /> m $? <br /> (signature of owner <br /> r b(uti�ldin contractor) (date) o <br /> ZONING ADMINISTRATOR <br /> El lA�+(Abf H(R 71 <br /> TOWNSHIP PERMITS MAY BE REQUIRED ti FIN o Noo��m <br /> vum <br />