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C- 1 C-) <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 - o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 _ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � H <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- 3 a <br /> t 'W <br /> of the State of, ' nsin. <br /> � o <br /> m <br /> m � <br /> c <br /> O N PI a Pr' Contractor or Surveyor or Agent a £ <br /> o � <br /> Addres Address m <br /> City„$tate, ip ;Z , 2�� City,State,Zip Code J <br /> 666/1/ // 1 /7/9J/�— <br /> Telep�ne ' Telephone � <br /> Em rgencylFire No. and Road N me <br /> Legal Description(as indicated on tax statement) <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision <br /> v <br /> Structure Use: o ° <br /> a <br /> (family me/cabin,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). p � <br /> 2. Show the location of the well(W),septic tank(ST), and drainfield (DF). Y <br /> 3. Show the location of any take or flowage-if within 1000 ft.and the location of any river or stream- if within 300 ft. 16, <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, C <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. O 3 <br /> PLOT PLAN Z v <br /> W <br /> M y <br /> cl <br /> a <br /> m s <br /> V) <br /> 3 <br /> SL0 <br /> �c o <br /> m <br /> o <br /> w <br /> Z <br /> m »�am aaA <br /> Z o: WOMM <br /> : 1 <br /> — ZE m <br /> 00 : Q <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ,C $ ': <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- Q:--: m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- < s Qi : p <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 99ly�. � �m v,; <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- <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 /> m N n <br /> � v v?� <br /> SIGN HERE �y � /C�D fl f'H o <br /> (sig of owner 'ding contractor) ( ate) o <br /> ZONING ADMINISTRATOR "+ <br /> TOWNSHIP PERMITS MAY BE REQUIRED N oo$m <br />