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n ! , V-), <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator i71 0 0 <br /> ' APPLICATION FOR — LAND USE — PERMITS3. - <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <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 n () <br /> tions of the State of Wisconsin. m o <br /> m <br /> m O <br /> OWNER(Please Print) Contractor or Surveyor or Agent n <br /> Address Address m <br /> /; zxsG �� �� p l✓v <br /> City,State,Zip Code City,State,Zip Code <br /> wa ii (_� �- V <br /> Telephone Telephone <br /> Emergency/rlre No.and Road Name <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for. <br /> New Building Sanitary Filling/Grading Camping Unit `; <br /> m <br /> Addition Privy Moving Subdivisionc 0 <br /> d OL-5-e P �o�^ �� <br /> Z a <br /> Structure Use: <br /> family home) in,garage,addition,etcV <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). r <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. 11 <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. M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 0 0 <br /> the owner. <br /> 11 a y <br /> Z c <br /> PLOT PLAN <br /> �5fe �1��lecl o <br /> Ci <br /> m <br /> � WI <br /> r <br /> I� <br /> c 1 <br /> �� " <br /> J Qr 5� c <br /> vE5 c"dj� $e(�e� Ise �te f- Q o f home f s <br /> T e reap r <br /> m csymcDiac� <br /> o � ooa—m <br /> m i£� —nm »na <br /> Z : <br /> 0 <br /> o: <br /> • i ?I N: � >D <br /> =6 <br /> o m`:, i O <br /> g a$ E C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- C" ? n? i m <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that 1 recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I p <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- i g-P 8:: <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. i O^v <br /> � 3 <br /> SIGN HERE �� hN <br /> natu o owner or b contractor) (date) ' o <br /> ZONING ADMINISTRATO ° <br /> to iw Hin iwwin 11 <br /> �rNi,uu Noob°m <br /> TOWNSHIP PERMITS MAY BE REQUIRED (� m <br /> _25ooa Ul <br />