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(3v\ C04y) f <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator W � 0 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- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. o <br /> N d <br /> y V <br /> C <br /> OWNER (Please Print) Contractor or Surveyor or Agent o f <br /> �' Ll'CC�. <br /> Address Address <br /> ��caller �� Sal�61 t <br /> City, Mate,Zip Code City,Slate, Zip Code <br /> (n <br /> Telephone Telephone I A <br /> Emergency/Fire No. and Road Name Q V' <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: n <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision B a <br /> v <br /> Structure Use: a o -� <br /> (family home/cabin, garage,type of addition,etc.) _ z <br /> C?� <br /> Directions for plot plan drawing: N <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. n <br /> O <br /> 3 <br /> PLOT PLAN a <br /> co <br /> Z c <br /> o a <br /> O _n <br /> N 0 <br /> O <br /> -C <br /> CV <br /> V' <br /> e <br /> N <br /> N <br /> �. <br /> N � <br /> N r <br /> O ' ^ <br /> J <br /> (1 <br /> N N � <br /> Z-f <br /> 71 <br /> ` ! >) my m r­ DDWa <br /> 0 c _.mw 0 <br /> A <br /> Z o: Z 1 <br /> O <br /> Ut P': O <br /> o; �-0- C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- O 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- N >- .,$ m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- (A ' 01 0: i G <br /> :a. <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 abov scribed premises at any reasonable time for the purpose of inspection. I :o:vi E <br /> m vim: <br /> tD N: <br /> SIGN HERE?1NISTRATOR <br /> ':v ioimvr <br /> (signature caner or building contractor) (date) om; no <br /> ZONING <br /> a� T <br /> Im <br /> N TU 00��$j <br /> TOWNSHIP PERMITS MAY BE REOUIRED o 0 0 0 o S N <br /> S <br />