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C111 C (' " <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,IW, 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONIN' 11NISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as-shop n.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- v <br /> nett County Lan. .Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. 3 a n <br /> tions of a State ut Wisconsin. � m o v <br /> u- 5- <br /> 0 <br /> OWNER (Pleas Print) Contractor or Surveyor or Agent o <br /> sr sw d <br /> Asf�ess Address '? <br /> lDC�tes7`�i /mayyQ <br /> City,State,Zip Code City,State,Zip Code <br /> I <br /> Telephone Telephone <br /> /-SG7��$7-�vG4%2 (4;35-P3W <br /> Emergency/Foad Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: G) <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> AdditionPrivy Moving Subdivision o ° <br /> i Pr v <br /> Structure Used XYV ��� o <br /> (family home/cabin, garage, type of addition, etc.) <br /> 7L <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). o <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 /> 3 <br /> PLOT PLAN <br /> o co <br /> Z a <br /> See 0 <br /> _ se� <br /> o <br /> 0 <br /> G <br /> 0 <br /> 0 <br /> IC <br /> z <br /> r � <br /> A c� a <br /> M ti ncmm <br /> n m <br /> O = d C N 0 0 <br /> fD <br /> of 4 <br /> O' o C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl. o l y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- 'o 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 1 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 /> /9 T <br /> SIGN HERE <br /> (si of owner or b 'Idi contractor) (date) E o o <br /> ZONING ADMINISTRATOR ] <br /> v% T N N O 1 V N <br /> TOWNSHIP PERMITS MAY BE REQUIRED P nNU O N <br /> 00000 0 <br /> 00000 0 <br />