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I I <br /> 1 . <br /> Burnett County 7410 Co. Rd. K, 0102, Siren, XI 54872 Office of Zoning Administrator y m o o <br /> APPLICATION FOR — LAND USE — PERMITS 3 JO TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 5located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m cnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 ntions of the State of Wisconsin. n <br /> 0 (Please Print) Contractor or Surveyor or Agent o <br /> /(t 2 mox /a GU ° <br /> Add es -. Address �" _ <br /> ' 7sken, Wi 5�87z <br /> City,State,Zip Code City,State,Zip Code r <br /> tic- 3 -5-357 J <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit GO <br /> 0 <br /> Privy Subdivision m <br /> Structure Use: ri�i✓� <br /> ° J <br /> (family home/cabin, garage,addition,etc.) o v <br /> m <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). M <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield(DF). <br /> I r- <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, / <br /> river or stream, if applicable. 'IUn <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> theowner. 6. Provide legal land description. <br /> O <br /> 0 <br /> PLOT PLAN <br /> a N <br /> Z a <br /> o n <br /> � a <br /> I y <br /> 0 <br /> I <br /> n <br /> Cl) e <br /> ria - <br /> �ti <br /> a <br /> v <br /> Qc rc� � <br /> m <br /> r <br /> T <br /> N � <br /> Z <br /> O <br /> Z <br /> Y J <br /> B � I1`GhG I� Sf <br /> U; <br /> m <br /> o: <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application includin an accompanyingschedule and I further declare that I recognize that O <br /> PP l 9 Y ) t p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing a <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. <br /> T <br /> N <br /> SIGN HERE /L"G'�. /.�! / y�C'TC��E��i�-' !' moi' - �7 q to <br /> (sign of owner or b 'Iding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> . � N N O N N T <br /> TOWNSHIP PERMITS MAY BE REQUIRED �° ��No. m <br /> 00000 oN <br />