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e,r, T, <br /> Burnett County 7410 Co. Rd. K, X1102, Siren, WI 54872 Office of Zoning Administrator m ' 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> N O <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 <br /> C <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 of Wisconsin. <br /> Ma K ause� o <br /> a — F <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> Address Addre s � <br /> h�PbSkef, UUs ��Ib <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o Z <br /> Sanitary Camping Unit C3 0 <br /> o <br /> Privy Subdivision 0 ,`�- <br /> m � <br /> E; <br /> Structure Use: v <br /> (family home/cabin, garage, addition,etc.) o c° <br /> m <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. ^°r. <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, <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6. Provide legal land description. <br /> O <br /> PLOT PLAN 3 <br /> a n <br /> Z `v <br /> O a <br /> V0 <br /> '0 <br /> N <br /> > <br /> 3 <br /> m <br /> 0 <br /> n <br /> Z <br /> O <br /> Z <br /> D <br /> o n C m <br /> a <° "Cm <br /> N Z <br /> 00 > <br /> OZ <br /> D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all : m <br /> PP (including Yaccompanying ) g A <br /> information contained in this application includin an schedule and I further declare that I recognize that p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a ' <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> (sign re of owner of building contractor) (date) <br /> r/J �[ o <br /> ZONING ADMINISTRATOR �.,�(fl./t <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> tit tTNN00(T <br /> 0000000fn <br />