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d-( , COOA C <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator I 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � 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- OR <br /> tions of the State of Wisconsin. m o <br /> _/t/ear •� <br /> Tel <br /> S <br /> 0 <br /> OWNER(Pleas Print) Contractor or Surveyor or Agent n :E <br /> 1?7 / QeX/O i/ Sf 130 <br /> Address Address m <br /> .SPooT .er cvi" J"Sl�o/ <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone l <br /> �e f wrX N <br /> Emergency/Fire No. and Road Name O <br /> Legal Description(as ndicated on tax statement) <br /> O <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition Privy Moving Subdivision S Cr <br /> � <br /> �`drClo <br /> �� x ° <br /> Structure Use: �y <br /> T - — a <br /> v (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). 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. 1A <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 v rn <br /> PLOT PLAN � o n <br /> s <br /> I <br /> C <br /> c m <br /> U = <br /> 0 <br /> -o U' <br /> m <br /> N <br /> w <br /> GZ <br /> 9 <br /> m c 2.,o a m <br /> W 1 <br /> v < d cow <br /> o ; <br /> C_ .^ Z O <br /> rn <br /> declare that this application(including an accompanyingschedule has been examined b me and to the best of m knowl- <br /> edge <br /> V'g <br /> PP (� 9 Y ) Y 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- �= ; a; m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i <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 County of Burnett relying on this information I am providing in this ap- i $a 8:: <br /> plication. I agree to permit county officials charged with administering county ordinances of other authorized person to have <br /> access to toe above described premises at any r rjable time for the purpose of inspection. <br /> � m <br /> m N <br /> SIGN HERE ` m <br /> (si na re of owns wilding contractor) (date) 4 f o <br /> r <br /> ZONING ADMINISTRATOR <br /> ,6i 6i y+lAMN(fq�7l <br /> NfNTNN OOO <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> m <br /> ogogggy <br />