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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Ca o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO TP,E ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions oyithe State of Wiscon in. ^� ('-. <br /> f�NNu belle 5k'CI� S I4 1 <br /> OWNS? .i-�(PeSase8Print) Contractor or Surveyor or Agent ii £ <br /> � � <br /> d <br /> Address r p� Address '3 <br /> 'l. ST�ga,l toN <br /> City,S Code City,State,Zip Code <br /> / - 7')o -/L143 ,-b <br /> Telephone POSJ" !1 Telephone O <br /> Emergency/F1 No. and oap N me <br /> !G)R r .iy �—, l �1 f s,G D 3/- Txley r?/y i-) - <br /> Legfil Description (as indicated on tax statement) <br /> o <br /> Permit(s)Applied for: n 0 <br /> New Building Sanitary Filling/Grading. Camping Unit 0 <br /> n <br /> Addition X Privy Moving Subdivision ° r; <br /> Structure Use: Z o <br /> 0 0 <br /> (family home/cabin,garage,addition,etc.) "I <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). o <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. <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. 'A <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated byO o <br /> the owner. <br /> 7Iv m <br /> PLOT PLAN 7I a a <br /> CN � <br /> r <br /> m � � <br /> C fi <br /> a <br /> kA O <br /> en <br /> o ° <br /> C_ �_ , <br /> N r <br /> 0 <br /> m <br /> v � <br /> a <br /> (� Z <br /> D <br /> I <br /> m <�m wr cDi nc�9 <br /> m ate '- am 'a9 <br /> c w o <br /> `2mo ?i0 — <br /> Z O: fQ. 1 <br /> mN: <br /> M <br /> LA 6e € i o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S; <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- - m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ; j g N O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <br /> further accept all liability which may be a result of the Count of Burnett relying on this information I am providing in this a $n o <br /> P Y Y Y Y 9 P 9� P- o; <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. E n»o <br /> ' 3 <br /> m oNs: <br /> SIGN <br /> (s' ture of ner wilding contractor) (date) o g' <br /> ZONING ADMINISTRATO <br /> �NNO NH� <br /> TOWNSHIP PERMITS MAY BE REQUIRED Fn v, m <br /> O u ,v, <br /> S$$8 S rn <br />