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(In cow IC' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d � <br /> � - o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- ..1 <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. <br /> n <br /> OWNER(Pleas Print) Contractor or Surveyor or Agent Q o <br /> �J, t� '� Y c.4 S-1�'- f%- _ �J, b ✓ ,��— „ V)� t/ <br /> Addtess q Address <br /> V <br /> �1- 11 > , I. �_4� s a I -/' , L , J Ste` <br /> City,State,Zip Code 7 City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name � <br /> Legal Description (as indicated on tax statement) CQ <br /> Permit(s)Applied for: 0 \ <br /> o <br /> New Building _ Sanitary Filling/Grading Camping Unit <br /> r <br /> Addition Privy Moving Subdivision o <br /> Structure Use: - - b o ° <br /> (family hom@(cabin, garage, typ of addition,etc.) _ <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). fn r <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. a <br /> 3 <br /> PLOT PLAN o m <br /> Z v <br /> 0,,``11 0. <br /> V <br /> 0 <br /> J �-O <br /> 0. <br /> o <br /> 9 o <br /> 1- 0 o <br /> 0 <br /> I� <br /> m e <br /> on n acmm <br /> n v' K,i wCmo3 3 <br /> Z T.: ? ry O . m <br /> Y•N N! <br /> L7� Cc 1. C) <br /> L7 <br /> I declare that this application(including O :o:y accompanying schedule)has been examined by me and to the best of my knowl- o ;, � : y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- ; c I ' m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation <br /> I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. <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- ii ;,,,,a' i <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 remises at an reasonable time for the purpose of inspection. <br /> P Y P P P <br /> G/-� p! <br /> SIGN HERE � . � <br /> (si at a of owner Ing contractor) (date) <br /> o S <br /> ZONING ADMINISTRATOR � y <br /> TOWNSHIP PERMITS MAY BE REQUIREDosu,tit v o o m <br /> Q' soss� y <br />