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Burnett County 7410 Co. Rd. K. . /102, Siren, NI 54872 Office of Zoning Administrator o Z <br /> APPLICATION FOR — LAND USE — PERMITS 3 P <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m o <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 o <br /> tions of the State of Wisconsin. <br /> U W N7E Ra(Please riot) a <br /> n j, Contractor or Surveyor or Agent F <br /> rC a <br /> Addf(e✓ ed^ f4a"/5 , /1/1 5 5 �d j� Address `D <br /> City,State,Zip Code Yv f City,State,Zip Code j <br /> 7� �`vzti �6y27 <br /> Telephone Telephone <br /> Permit(s)Applied for. p <br /> New Building Filling/Grading <br /> Addition Moving 6 <br /> 0 <br /> Sanitary Camping Unit <br /> PrivySubdivision o' <br /> 0 oa1 / r <br /> Structure Use: D /] S r'. o � <br /> (family home/cabin, garage,addition,etc.) <br /> Z <br /> o 0 <br /> v <br /> Directions for plot plan drawing: m <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. o <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 /> PLOT PLAN o <br /> 4 V <br /> -- <br /> L_ cbly Laov e o g <br /> Lot 16 7y <br /> 1 � <br /> --D <br /> I � <br /> F m <br /> 0 <br /> 3 S z o <br /> 0 <br /> 0wl M N V N r D <br /> fake � <br /> colo <br /> 6L7CCN m ` " m <br /> . nc a - a <br /> F. -o: 2 <br /> y [ 71 <br /> «` i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c C_ <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and secure <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that J p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue aJ oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing m ; <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized P <br /> person to have a cess to thea ve described premises at any reasonable time for the purpose of inspection. A <br /> N <br /> SIGN HERE , <br /> (si ure of owner Qr building contractor) (date) I (.l <br /> ZONING ADMINISTRATOR i{"� In <br /> of <br /> O N N O N++N <br /> - TOWNSHIP PERMITS MAY BE REQUIRED G <br /> 0000000 <br />