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C7 rl co PY-1 T <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Q 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3' <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- S <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 a <br /> tions of the State of Wisconsin. y <br /> DnO UECVVe C <br /> o <br /> O R(Please Print) Contractor or Surveyor or Agent o m <br /> 06 ay-tl.. AVE ME- <br /> A Address <br /> rCl?70'`-0IJ'171ae,Zip Q City, State,Zip Code <br /> 2 ." Q00 ,1•_7 cri <br /> Telephone IC3 OYe141AMf" Telephone J <br /> Emer ency/Fire No. an Road Name � <br /> I�E y� Sl��y S 23`r 40 MIR IS 0 � <br /> Legal Description (as indicated on tax statement o <br /> Permits)Applied for o <br /> 771 <br /> New Building Sanitary 'X_ Filling/Grading Camping Unit y <br /> r <br /> Addition Privy Moving Subdivision o » <br /> v <br /> Structure Use: Z a <br /> 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(NB)and indicate North (N). <br /> 2. Show the location of the well (W), septic tank(ST), and drainfield(DF). -°r. <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. Q <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 /> o <br /> PLOT PLAN 3 <br /> a y <br /> 2 T <br /> o d a ly+ <br /> 0 <br /> I <br /> O <br /> C I� <br /> (� Z <br /> m <br /> Q , o <br /> C G � <br /> N fm <br /> 0 <br /> Cn <br /> 0 <br /> I Z <br /> I <br /> G <br /> N C M N r (> n Cca <br /> -0 <br /> -'n m »n y <br /> o <' p1Cwo'= 3 <br /> Z N N O nn <br /> o ° Ni [ A <br /> Nom: m <br /> o: <br /> O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- Ao m <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 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 described premises at any reasonable time for the purpose of inspection. <br /> m <br /> - 90 <br /> SIGN HERE <br /> (signature of r or 'I contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> g , � -n <br /> TOWNSHIP PERMITS MAY BE REQUIRED �(�o 0 088 fmA <br />