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O'c1 C c�- � C� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS '- 3. <br /> T <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- m a <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of tha State of Wisconsin. <br /> "So W Se, m m ly <br /> OWNER Please rint m {} O <br /> ( ) Contractor or Surveyor or Agent n <br /> 11 s37 N- SAO-e Drt,,-ea <br /> Addr °1 m <br /> ( Wt 3 � vo Address <br /> City,State,Zip Code City,State,Zip Code <br /> T <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name r <br /> Legal Description(as indicated on tax statement) <br /> o � <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit o M <br /> N <br /> Addition Privy Moving Subdivision 8 <br /> Structure Use:_ 7Q .��/Q o <br /> (family homelcabin, garage, addition,etc.) <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(ES)and all new buildings(NS)and indicate North(N). r <br /> 2. Show the location of the well (W), septic tank(ST),and drainfield(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 to lake, 0 <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 O <br /> the owner. C 3 <br /> PLOT PLAN Z c <br /> o a <br /> y. <br /> tj <br /> 4 <br /> co <br /> W e <br /> o <br /> ) a n_ <br /> r o <br /> o <br /> m <br /> v 1 <br /> w <br /> 1N� Z <br /> � mvfnr DDcoy <br /> n <br /> o- <br /> m a nm ;a9 <br /> M Cn 7J <br /> C =2 m <br /> O <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> edge U <br /> PP ( 9 Y ) Y Y rCo i m m : gp <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- p-=? ; 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 c-1 `a m P <br /> further accept all liability which may be a result of the Count of Burnett relying on this information I am providing in this a - r` ` n c <br /> P Y Y Y Y 9 P 9 P E $� o; <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE /0 / d' N <br /> m 0 <br /> si atur of owner or buil incontractor) <br /> ( 9 (date) o <br /> ZONING ADMINISTRATOR <br /> in in+'sA iw inw 7l <br /> TOWNSHIP PERMITS MAY BE REQUIRED r, N n o o m <br /> �oo$Sgggrmil <br />