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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator ( 0 <br /> 0 <br /> APPLICATION FOR — LAND USE — PERMITS 33 t <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'Z y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements ri the Bur- <br /> tions <br /> ur- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and re Bur- 3 a <br /> tionslof the State of Wisconsin. / A d/z'o <br /> ig, <br /> qWN,ER(Please Print) © Contractor or Sury yor or A�gent <br /> Address Led QLP C 00=) P [Sro�,,, d J <br /> Addr as <br /> Gy� Mra" AS, , 416.1 <br /> City,State,Zip Code City, tate,p Code (A <br /> s.3 3 - C <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building X Filling/Grading <br /> Addition Moving o 0 <br /> Sanitary Camping Unit M <br /> PrivySubdivision 0 0 G <br /> Structure Use: Scre-etA 1TDuse. o <br /> (family homelcabin, garage,addition,etc.) z o f <br /> o <br /> m <br /> Directions for plot plan drawing: z <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). <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 submittgd by an aTh(tect,en ineer, buildpr,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6. Provioe legal land description. <br /> 0 <br /> PLOT PLAN 0 <br /> Z c <br /> II^^\\ ! <br /> A ' Q <br /> w 0 <br /> J <br /> / 1 <br /> S, i5c` 0 <br /> o <br /> J <br /> \4 , <br /> l-7 – — <br /> �p� <br /> \ l o <br /> / a ' Z <br /> r(A <br /> 9 W MCnr-DD W 10 <br /> a0 anXl <br /> Z y ? c owo J a 3 <br /> m <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 <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize thatA : p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a V 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 a <br /> person to have access to the above describ premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE 7 w <br /> (si ur owner or g contractor) ate) p <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED oogN \ <br />