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-yi (00P <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m <br /> TO TFCE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '5 m G <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tion s of he State of Wi opsin. o <br /> OWNER PI ase in Contractor or Surveyor or Agent n F <br /> 5 Pr�) /.i. Sf o <br /> Address/) SSS/. / Address �? <br /> City, <br /> �$f�ate,Zip pode�- /' ••V GfL City,State,Zip Code <br /> Telephone �/ (�[ Telephone <br /> roI <br /> Em re o and Road Name <br /> w7Ir/�/, Z4In <br /> Legal Description(as indibaVed on tax statement) <br /> o <br /> Permit(s)Applied for: 0 <br /> o <br /> New Building Sanitary JL Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision <br /> iy�au/ d/zLc/ <br /> Structure Use: o ° <br /> a <br /> (fafnily homelca n, garage, addition,etc.) <br /> Directions for plot plan drawing: <br /> W <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). o <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, Q <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 byO O <br /> the owner. <br /> 1Ia m <br /> PLOT PLAN <br /> Z n <br /> m � 3 <br /> (A U' <br /> SU 3P <br /> c <br /> rn <br /> o <br /> O <br /> V <br /> iN <br /> m <br /> v � <br /> » 1 <br /> 0` Z <br /> /v � <br /> I <br /> ]o NvrAr DDm� <br /> m n'I '--.am <br /> '^ mp �m' �' <br /> Z of <br /> P T(» <br /> � M <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> PP ( 9 Y ) Y Y o: <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 /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- //� ' 3A o'i* E O <br /> : ON <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I .`d m <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- $a $ <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. O»v <br /> T n <br /> ON0 <br /> SIGN HERE <br /> (si natur of owner or bu' contractor) / (date) ' o <br /> O: <br /> ZONING ADMINISTRATOR o' <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 0 <br /> 'aaaa00 <br /> 0000g$ofmA <br />