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oa co; � <br /> Burnett'County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator co d -o c c <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> ;u o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -0 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 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n r+, <br /> tions of the State of Wisconsin. ,/ m <br /> Do& J.A.A OF 7ERPETURL/�CZ/� w <br /> OWN`E[R(Please Print) Contractor or Surveyor or Agent n F <br /> /�/�.H.• AY 77 m t, <br /> Address Address = I to <br /> 17g,u8�a1 Gf/ic�3o 6- <br /> City,State,Zip Code City,State,Zip Code In <br /> t I <br /> �. <br /> Telephone Telephone N _s) A <br /> 11-wY 77 Cy O <br /> Emergency/Fire No. and Road Name p <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N t <br /> Addition �� Privy Moving Subdivision gC <br /> v � <br /> Structure Use: v° <br /> (family home/cabin,garage,addition,etc.) I <br /> Directions for plot plan drawing: (� r <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). N b <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. -0 <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. 31 (� <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 /> o1 vthe owner. <br /> rn <br /> PLOT PLANZ a <br /> e/M 7 7� I�l�`l Z 111 (,v1 ' a I\ <br /> C <br /> P.coT /fit-A,v — SEr �TTAG//`.b � .n <br /> M 'C <br /> o D <br /> r o <br /> � F <br /> O U m <br /> C n_ <br /> O <br /> o <br /> 0 <br /> m <br /> O � <br /> m <br /> i <br /> Z <br /> I � s <br /> y N'O rn�DDCoy <br /> m <br /> stare_ Plu aGp«,« IMA f// Z o : m z FMm <br /> M : T_N: : M <br /> f�g <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> edge <br /> PP ( 9 Y ) Y Y o : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- O= E m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- H N O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 <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 top it county offici Is charged with administering county ordinances or other authorized person to have <br /> access to the above a rlbed premis at any reasonable time for the purpose of inspection. i O. <br /> m E d0 i <br /> SIGN HERE <br /> (sig r of ow er or i ing contractor) (date) 8i F,i - <br /> ZONING AD (N/IRATO <br /> R ? ` i `• <br /> fA VIN+(A!A VIN�t <br /> N N O N P P. M <br /> TOWNSHIP PERMITS MAY BE REQUIRED C m <br /> $S$$$$$(n <br />