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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator <br /> APPLICATION FOR - LAND USE - PERMITS � 3. <br /> TO THE Z0,NING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m o <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- N 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 of the State ofyVisconsin. <br /> � k' 1YZ ,t' .S h11,2fx / J, i; `iL ' -(,)A !' O <br /> / <br /> O ER(P ease Pnnt) ^ / !'� Contractor or Surveyor or Age/n-t <br /> pC j�� d �/T �'�' /5%-�_ - � .�t`�< ,Y !' ✓�r� !J C'i'r�d 117 = �_ <br /> Address Address - m <br /> 5-�tJ `f�� e `er Mfr, s/rJ � <br /> City,State,Zip Code City,State,Zip ode <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name <br /> 1v /� Vi,v - / ,' i s4 Z A d� � <br /> Legal Descri tion(as in bated on tax statement) p n <br /> Permit(s)Applied for: o V <br /> Filling/Grading Fillin <br /> New Building Sanitary 1''J 9 9 Camping in 9 Unit w <br /> r <br /> Addition Privy Moving Subdivision g » <br /> Nei Onl <br /> Z o <br /> Structure Use: <br /> (family homelcabin, garage addition,etc.) <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). <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. 9 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by C 9 <br /> the owner. 93 ur <br /> c <br /> PLOT PLAN 7 c Cr <br /> (A 9 . <br /> I <br /> i <br /> 0 <br /> o <br /> o <br /> w <br /> Z <br /> N D <br /> a <br /> f <br /> M c=m S;0>aamA <br /> m i'l '-'am nas <br /> a < m Cwoo; <br /> w: o m — <br /> Z o i 1 <br /> N: ! A <br /> p <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- mi <br /> o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- n: m <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. w un <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- E 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..o <br /> T of 0 <br /> m € 3 «x <br /> / (signal of own or building contractor) <br /> ✓ <br /> SIGN HERE t � .(✓x� <br /> 1 Ir-I/VI fi [ E <br /> ZONING ADMINISTRATORi4,n <br /> rJ1��V <br /> vN N o o m <br /> TOWNSHIP PERMITS MAY BE RED1llkED 8 S88rn <br />