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Burnett County 741C Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> --r 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 <br /> N <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,, nd. with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. ke-CL <br /> N � <br /> �)ff) () (ctx�A �15 UJ0.jn4 � r u i y 1 <br /> OWNER(Please Print) Contractor or Surveyor or Agento. <br /> L` (OiL -lO-r)d <br /> Address Address <br /> LAJ <br /> City, State,Zip Code r ` City,State,Zip Code <br /> c2S �0 �0— �Z ( S rOv vD <br /> elephone Telephone rylO.,Y- <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Pl- <br /> Permit(s)Applied for: <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision <br /> Vv <br /> Structure Use: 0 0 <br /> (family home/cabin, garage,type of addition, etc.) m <br /> z , <br /> �c <br /> Directions for plot plan drawing: Un <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 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. O <br /> 0 <br /> PLOT PLAN v <br /> Z v <br /> 2 0 a <br /> 0 <br /> w <br /> o <br /> In y <br /> a� a <br /> N <br /> O 1 <br /> 0 <br /> O <br /> O <br /> » I <br /> Z <br /> CS <br /> G <br /> N G 'o N r O O.co M <br /> n0. m <br /> N � 0 0 M Q <br /> � a:df m <br /> S tio;• : c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i '• 0 Ec� <br /> edge and belief It is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- c[a m <br /> tion contained in this application(including any accompanying schedule)and '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 a <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 da cribed premises at any reasonable time for the purpose of inspection. <br /> C>. oH: <br /> D n <br /> _ U[ sp o <br /> RE (si at re owner g contractor) (date) <br /> 'BATOR �`^� i gm i ;moo <br /> t' 3k <br /> IV ON ;nom <br /> TOWNSHIP PERMITS MAY BE REQUIRED cep m <br /> g 0000� tA <br />