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Ul <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> y <br /> TO TI,. ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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- 3 v <br /> tions of the Slate of Wisconsin. <br /> LLS S7N y <br /> o <br /> a <br /> OWNER(Please Print „ Contractor or Surveyor or Agent o m <br /> jawpso <br /> V C m <br /> Address Address I � ,V <br /> City,State,Zip Code City, State,Zip Code S <br /> f <br /> Telephone Telephone <br /> Emergent (Fire N . and Road Name <br /> Lega�scripLon(as indicated on tax statement) Q <br /> 0 <br /> n c) <br /> Permit(s)Applied for: ^ <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit J <br /> m <br /> Addition Privy Moving Subdivision o <br /> v <br /> Z o <br /> Structure Use: P <br /> (family home/cabin, garage, type of addition, etc.) m <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). <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. V' <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 O <br /> the owner. <br /> 3 <br /> a <br /> PLOT PLAN Z c <br /> P c m <br /> a <br /> r O <br /> C <br /> a <br /> N I� <br /> o � <br /> 3 <br /> b <br /> N <br /> Z <br /> G <br /> M NV En r- DDm <br /> m a- <br /> 8,< a o FL <br /> F. Z ur wo 3 <br /> N <br /> Z O <br /> P J <br /> U); In <br /> 9 <br /> O <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- o: '. iS <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- fv o G <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- f n y <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I V� 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. m <br /> m <br /> m <br /> SIGN HERE <br /> ` d' <br /> (sign r f owner ilding contractor) (date) (�;' o t o <br /> o: o <br /> ZONING ADMINISTRATOR <br /> —8" m <br /> TOWNSHIP PER MAY BE REQUIRED N <br /> 0 0 000 <br /> 0 0 000fA <br />