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on Cc)m <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administr tor 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> s X1—,1 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � w <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 n f <br /> tions of the State of Wisconsin. - o <br /> OWNER(Please Print) Contractor or Surveyor or Agent °- f <br /> ,tet <br /> Address Address <br /> City, State,Zip Code City,State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No; and Road Name V <br /> S" 33 iT�ZC elf'JA (A ) T.4A aReE'lgc' "v C" <br /> Legal Descripti n (as indicat�tax statement) p <br /> Permits)Applied for: <br /> m <br /> 0 <br /> New Building . Sanitary Filling/Grading Camping Unit <br /> Addition _ _ Privy Moving /Subdivision g <br /> / flu <br /> Structure Use: G�'"��-{ti-� ��� � ? � �� �(Pb o 0 <br /> (family home/cabin, garage, type of addition,etc.) m fp <br /> � V <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). .0r. <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 /> 0 <br /> PLOT PLAN 3 <br /> — a <br /> 0 <br /> O <br /> I n <br /> � w <br /> C <br /> V ) f JV <br /> � r <br /> 0 <br /> b� <br /> S6tl rgrv °s <br /> N z <br /> [?Yv <br /> l� 0 3�• ro <br /> 0 0-c » 0 a= m <br /> T a <br /> Z ni m C . 5�O' <br /> 0 0 i ` 'z ;u <br /> ��h E 7^ M <br /> co m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o: �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- m <br /> o: <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-a <br /> further accept all liability which may be a result of the Count of Burnett relying on this information I am providing <br /> P Y Y Y Y 9 p gin 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. b <br /> T <br /> fD v <br /> N <br /> SIGN HERE <br /> �m <br /> n ture of owner or building contractor) (date) o.0 imp <br /> b it mo <br /> ZONING ADMI TRATOR� lll/I�/ 7 <br /> lam/ O of i^iu T <br /> N N O <br /> TOWNSHIP PERMITS MAY BE REQUIRED CN v u N <br /> O o ar m <br /> 00000g�l`Vl <br />