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!� C <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o a <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> m o b <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� w <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- n /k <br /> tionsofthe State of <br /> of Wisconsin. <br /> C <br /> OWNE <br /> Nsep i Contractor or Surveyor or AgentLid <br /> o f <br /> m 1 m <br /> Address m, <br /> 1 ! V - <br /> Ciiv,i to Zip ode oto City,State,Zip Code <br /> ) <br /> Tel pbnnephone 1 ^� <br /> 0 <br /> Eme ncylFire No.and Road N .,.�... P <br /> ;� �r x�i La l t a <br /> Legal Description(as indicated on tax statement) f —L # <br /> 1 u 1 D <br /> Permit(s)Applied for. <br /> � o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition (� Privy Moving Subdivision c 0 <br /> Structure Use: ' [1:M �r b(iy-j�f ( [RDLA 0 r VXft .��� o a <br /> I (family home/cabin,garage,addition,etc.) a <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). 1 r <br /> 2. Show the location of the well(W) septic tank(ST),and drainfield(DF). F' <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. 1$" <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 <br /> the owner. <br /> v <br /> PLOT PLAN w <br /> Ms <br /> 710o <br /> N <br /> 0, \ <br /> - t o <br /> i_— <br /> T 'T-Y) j r <br /> i <br /> m cam m nc m <br /> moo; <br /> 2 j ` m <br /> 01 <br /> O <br /> I declare that this a Iicatlo ludin an accompanyingschedule has been examined b me and to the best of m know]- <br /> PP 9 Y ) Y Y 0 , mm ; y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I 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 '• `a 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. O p' <br /> SIGN HERE at A <br /> m 6- <br /> (a r1rto of owner, ilding contractor) (date) o <br /> ZONING ADMINISTRATOR <br /> rA��HH' <br /> N N O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 00000' c <br /> 00000 0 <br />