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rY" <br /> Burnett County 7410 Co. Rd. K, #102, Siren, MI 54872 <br /> Office of Zoning Administratorm M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 3 — <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m f <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m0 s <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a N <br /> tions of the State of Wisconsin. O <br /> N d <br /> /n1 <br /> 0-3 1A e <br /> OWNER(Please Print) Contractor or Surveyor or Agent p <br /> ,!� � ' n ' L_ �/ /� Address S <br /> AdfFY <br /> City,State,Zip Code <br /> City,State,Zip Code <br /> -71 e7l _' <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> Camping Unit o <br /> Sanitary o <br /> Privy Subdivision <br /> m <br /> L o' <br /> Structure Use: 0.m I r Il m 4L <br /> (family h melcabin,garage, addition,etc.) o �° <br /> m / <br /> c — <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). r- <br /> 3. <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. o <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 lake, <br /> 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. 4 Provide n <br /> 0 <br /> 3 <br /> PLOT PLAN P rn <br /> Z `v <br /> P a <br /> o <br /> 1 <br /> IU <br /> CDr <br /> i V 26 N <br /> syr c-a aiJ <br /> ° <br /> D <br /> o � <br /> y r � <br /> w <br /> Z �� <br /> o IKT <br /> (J n vi m<n r a <br /> S <br /> o <br /> �— o <br /> rn <br /> JNrT ��l � 711 �J o 15 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all - n m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m <br /> SIGN HERE f 9i <br /> signature ner or buil i ontractor) (date) <br /> ZONING ADMINISTRATORryT <br /> IV N O IV�lpp/y++����N m <br /> OWNSHIP PERMITS MAY BE REQUIRED N-606 <br /> NNOlp{nm <br /> 0 <br />