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(3(1 Co M f <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 S <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a J <br /> tions of the State of Wisconsin. p <br /> N <br /> 1C:��ARGF�Xi7" oto /'i o�E Se � T>- <br /> OWNER (Please Print) Contractor or Surveyor or Agent o F <br /> T d <br /> m <br /> Address Address <br /> City,State,Zip Code City, State,Zip Code <br /> 5- -a3 :3 <br /> Telephone Telephone lam, <br /> 6 /2- X37- 530 3 IF , <br /> Emergency/Fire No. and Road Name <br /> JQZeZ R/) Cy <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision g <br /> Structure Use: 0 0 <br /> (family home/cabin, garage,type of addition,etc.) <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings (NS)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 ordi- <br /> nary high water mark of lake, 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. 0 <br /> 0 <br /> PLOT PLAN -30 <br /> error So, t s7` N <br /> See 'C'4N �erm� Z a <br /> 0 <br /> / <br /> o <br /> W <br /> 0 <br /> N <br /> 0 <br /> Z <br /> J <br /> a< 3a0aaz <br /> o < p1Cwo'o 3 <br /> Z <br /> f0 <br /> 0 <br /> m <br /> O NC :N <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> edge <br /> PP (� 9 Y 1 Y Y o <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa. G— m 'o m <br /> tion contained in this application(including any accompanying schedule)and I furtherdeclare that 1 recognize that this infor- 0 i <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 to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> T N: <br /> /f� 7 u- 9- 9O nom; <br /> SIGN HE E y :o: <br /> s atur oftener ildin contractor <br /> ( � 9 ) (date) oa : :00 <br /> ZONING ADMINISTRATOR <br /> ai :n[u <br /> VNi UtN(NTOO <br /> TOWNSHIP PERMITS MAY BE REQUIRED O M <br /> �o 000o y <br />