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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm 0 0 0 <br /> '— 3 f <br /> APPLICATION FOR — LAND USE — PERMITS d <br /> TO THEZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and s� y <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- 3 a <br /> tions of the State of Wisconsin. m (TN <br /> OWN R Please Prin Contractor or Surveyor or Agent o. f <br /> OMS s � Mint e Ay- <br /> d (/1 a A <br /> A Wss Address tiff zl <br /> keAVL M� �s ►oS <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone a <br /> Vn <br /> Emergency/Fire No. and Road Name ^: <br /> Legal Description(as indicated on tax statement) V' <br /> Permit(s)Applied for: 0 C <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit w <br /> r <br /> Addition Privy Moving Subdivision o <br /> Z <br /> v <br /> Structure Use: 9 c° <br /> (family homelcabin, garage,type of addition,etc.) <br /> r <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). 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. f� " <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. o <br /> 3 <br /> PLOT PLAN 'p m <br /> Z C <br /> o <br /> �L y <br /> 1 = <br /> w <br /> �- <br /> 0 <br /> N IW <br /> O <br /> _ <br /> J <br /> C] <br /> N � <br /> I� <br /> Z <br /> I� <br /> NC �N N OaCmm <br /> M ar yam aaM <br /> a m Z m p M 9 3 <br /> m <br /> 9 � E D <br /> 2; m <br /> ao: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all inforni m <br /> tion contained in this application(including an accompanyingschedule and I further declare that I recognize that this inforru <br /> PP ( 9 Y ) 9 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. a E : <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this apt A <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to hav <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE �1 N <br /> (sign a of owner ding contractor) (date) <br /> o: <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED bN. " �� m <br /> $ootm/1 <br />