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I ,I <br /> Jurnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <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. <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0- <br /> tions of the State of Wisconsin. o <br /> �I,X1'02 Gy-�TOANA�e ,y clSeN ��% <br /> OWNER (Please Print) Contractor Surveyor or Agent_11e; Alov <br /> o <br /> Address yrs Address <br /> City,State,Zip Code City, State,Zip Code <br /> 2/, — 3e'G <br /> Telephone Telephone <br /> yyG� 2�'v �7;L r�fp� <br /> WA� < � <br /> Emergency/Fire No. and Road Name <br /> bot` 37 ter p.4)1AAt l t Arg AA,O 7'd 1/iyAo et� 1/�7 <br /> Legal Description (as indicated on tax statement) y °—� v /� <br /> Permit(s)Applied for: <br /> 0 <br /> New Building /� Sanitary Filling/Grading Camping Unit 3 <br /> ' r <br /> Addition Privy r� Moving � Subdivision $ o <br /> Structure Use: Cr41 <br /> Al / D Z o <br /> (family home/cabin, garage,type of addition,etc.) 0m <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 1 <br /> the owner. ct <br /> 0 <br /> PLOT PLAN N <br /> Y Z c <br /> l/ O <br /> 1 7 <br /> 1 \ <br /> ya f <br /> N <br /> N <br /> OF N 2 <br /> o <br /> �4V 31 I <br /> Y 1 <br /> y <br /> !�Y <br /> N c�N N 0 a Cm m <br /> m 0.- <br /> r - co 5's <br /> Z o Z fo O O <br /> par 0 : fD .z : i -t <br /> of ` O <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- o <br /> -o I [ 0 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- ao 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 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. <br /> m <br /> SIGN HERE <br /> (si atur of Owner or build' ontractor) (date) ", N <br /> o: o <br /> ZONING ADMINISTRATOR <br /> NNOIv��f]�J�r�J <br /> TOWNSHIP PERMITS MAS BE REQUIRED <br /> C000000l\\Fb�jJ!{//91 <br />