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Burnett County 7410 Co. Rd. K, 1102, Siren, wt 54872 Office of Zoning Administrator m 'o Z <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> o <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 /> 0 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> do of the State of Wisconsin. <br /> /� -jam <br /> arra f 44,p-e5 ja�/ oro <br /> a o <br /> OWN ( lease Print) Contractor or Surveyor or Agent <br /> Addr s Address <br /> P 1eafcr I19N <br /> City, Ip Code City,State,Zip Code t d <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building X Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit 0 <br /> 0 <br /> o < <br /> Privy Subdivision J ,: <br /> �W& ole S&�& i a <br /> a <br /> Structure Use: !R!^ Y <br /> (family home/cabin,gar e,addition etc.) 0 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_ () <br /> 0 <br /> PLOT PLAN 3 <br /> o y <br /> ` _ c <br /> Fit me. eoz,e- 1lak� o n <br /> N <br /> O <br /> 901 <br /> m <br /> n <br /> o <br /> er o <br /> Cee <br /> Z <br /> IaI &9 ror <br /> - I 1 )o 9 � <br /> am.NmOc <br /> e a <br /> O J <br /> N 0 O J <br /> N <br /> oM <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all <br /> ' m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that Ao : O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o - <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <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 describe Npremises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE �' v <br /> ( ' patre of own r or ing contractor) (dat ) [ N <br /> ZONING ADMINISTRATOR rrAA o' <br /> v4 <br /> TOWNSHIP PERR84 MAY BE REQUIRED <br /> PNN TO N <br /> b000$ o <br />