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U Y I L U ` I r <br /> Burnett County 7410 Co. Rd: K, No. 102, Siren, WI 54872 Office of Zoning Administrator (n m o oZ <br /> APPLICATION FOR — LAND USE — PERMITS f <br /> w � o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and rn <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of thStateof Wisconsin. <br /> 12onall * &rL11s41 Le-m A r-e &-CZG{!1 cLe,'l r'r e r <br /> OWNER(Please Print) Contractor VSurveyor or Agent Ep <br /> HI05 /VtiNCV Pilo .. , i w <br /> CD <br /> Address c� 4 <br /> �horevrew, !" 11�1v1�"„5i�}4 roH�'�;��o� ,M� SE;z6S � I <br /> CI�v,State,Zip Code City,S ate,Zlp Code <br /> 112) 483 -� � t515�t5is,•3050 <br /> Toephone � �'74 !�Pr+i ��Fe ) Telephone <br /> E ergency/F1{a No.and Ro Name L 4 Q r <br /> {oa+zep jA Sr-PLI n� /UC- J/H-� 5 / T .ya f I� I� �1 <br /> Legs Description(as indicated on tax statement) <br /> 0 <br /> Permlt(s)Applied for: <br /> New Building yy Sanitary Filling/Grading Camping Unit <br /> Addition �C�._ Privy Moving Subdivision c <br /> Structure Use: �1 c o <br /> (family home/cabin, garage,addition,etc.) $ <br /> K <br /> Directions for plot plan drawing: C` <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and Indicate North(N). m <br /> 2. Show the location of the well (W), septic tank(ST),and dralnfield(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. <br /> 4. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building t. lake, <br /> river or stream, If applicable. 0 <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. C <br /> PLOT PLAN (n <br /> � o g <br /> M <br /> /''\kv;41 r.f a L4'c C I <br /> mI� <br /> n <br /> CP <br /> 3Cn, <br /> ,( <br /> �^ 0' G o <br /> 13 <br /> I <br /> N <br /> i 0 <br /> DeJA aJK rows G z <br /> T <br /> J � <br /> NDN DDaO'O <br /> G co r:aASEM�j <br /> 9 y Z y 0 m o it <br /> c . Q =1 <br /> MI 21 <br /> ;E 2i m <br /> g i m cIdeclare that this application(including iny accompanying schedule)has been examined by me i i C <br /> and to the best of my knowl- c, <br /> edge and belief It is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 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 . <br /> further accept all liability which may be a result of the County Burnett Wisconsin In determining whether to Issue a permitI <br /> 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 /> SIGN HER <br /> (s ure of own building contractor) (date) o i S <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP P RMITS MAY BE REQUIRED NS o m <br />