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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o Z <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> w o <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 <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 <br /> the State of Wisconsin. <br /> / BBV �r4ri - rQn L/ G .LiCths m <br /> OWNER(Plea a Print) —� n O <br /> r Contractor or Surveyor or Agent f <br /> �-, /t L <br /> Addre�s/s� / y Address�/J / / <br /> Y./2..i h c[.r�� t✓/:�G. / Q ((/a, Li er y tc,r 'Sc- <br /> City, State,Zip Code City, State,Zip Code (� <br /> Telephone Telephone IP <br /> Q I}o <br /> Emergency/Fire No.-and Road Name D <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision g <br /> JC/Ccn ©u�c� <br /> Structure Use: - Zo <br /> (family home/cabin, garage,type of addition,etc.) P 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). 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. <br /> O <br /> 0 <br /> PLOT PLAN 3a <br /> / / L n <br /> o n <br /> N <br /> O <br /> V' <br /> 0 <br /> f <br /> N <br /> F m <br /> v , � d O <br /> 0 <br /> 13 <br /> a� o <br /> ' n <br /> r Z <br /> /a`µ <br /> 0 sz,� <br /> ` bma ' ' ma TU J � —cn <br /> M <br /> D.ii STl✓� S(%1 b�"L K. -p' �.: N <br /> Co O O 3 <br /> i�2 �. m <br /> m <br /> :\O C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- N O o :m, ; —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- i " m <br /> mol <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 permitI ' ma <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this [ws <br /> alp- <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 /> T :N; <br /> SIGN HERE <br /> (sign ur of owner ilding contractor) (date) <br /> 0 0: imp <br /> ZONING ADMINISTRATOR /G _ <br /> L:ni :I,o <br /> u nhT <br /> TOumWNSHIP PERMITS MAY BE REQUIRED urn 0 n o o w <br /> 000000rh/11 <br />