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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratoro 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 m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- mc `,A <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 00 <br /> 3 a vt � <br /> -160 <br /> tI is of the State o Wisconsin. / w o F <br /> l L,R �.,ltk2 ,� e- d = o <br /> c <br /> OWNER(Please Print) Contractor or Surveyor or Agent n �, <br /> A�1I�ress Address g I <br /> Inn ev / W 6St(Uu I Ic C� <br /> City,State,tip Code City,State,Zip Code I r <br /> f (715) Xt--742- <br /> Telephone Telephone <br /> Emergency/Fire No.a Rad Name <br /> R 15-w In <br /> r-' <br /> Legal Description (as indicated on tax statement) I o .0 <br /> Perndt(5)Applied for. ... ,_. .___..,.....-..,,_�.. .. <br /> New Building Sanitary Filling/Grading Camping Unit <br /> O r <br /> Addition Privy Moving Subdivision g Q <br /> (/// / v <br /> Structure Use: C"'6 �� Y" ya `� P m <br /> v <br /> (family home/cabin, garage, 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). L1 or <br /> 2. Show the location of the well(W) septic tank(ST),and drainfield(DF). 7 <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. -4 _ _ \ <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, 0' <br /> 3 <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 O <br /> the owner. 0 3 7 <br /> G m <br /> PLOT PLAN '—' Zn a <br /> _. � o a <br /> M <br /> 1 � <br /> b � Ir <br /> so� � <br /> D <br /> gay 17 <br /> m � <br /> m < : W nn9 <br /> 9 <° mCgp � <br /> Z !p `Z X0010 ; <br /> (,A- »' O <br /> �C^_i i ma <br /> I declare that this application(including any accompanying schedule)has been examined by me and to th best of my knowl- g; m m , A <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- �•= : n m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- d'i ' ; N 813 <br /> O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 i o m P <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 �y I <br /> access to the above described premises at any reasonable time for the purpose of Inspection. f ? E @O@ ^o E <br /> SIGN HERE LA <br /> is a re of owner r uilding contractor) (date) <br /> ZONING ADMINISTRATOR ` $ <br /> QN ONHNyI TI <br /> TOWNSHIP PERMITS MAY BE REQUIRED fTO,00l{prpeVV.y�m <br /> r'F <br /> L'8 1` 8 8 <br />