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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 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 y <br /> located as shoym herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions aState of Wisconsin. p <br /> V. w w <br /> ---7 �/ // g <br /> R(P ease P t) ontractcr or Surveyor or Agent F <br /> �,l, <br /> Addrei s .y� ll Address <br /> CI�1fi2ch Zip �J A ) 7037 City, S te,Zi Code 1•— <br /> Te hone^ Telephane <br /> Emergency/Fire No. and Road Name <br /> �Qr R AL 0.'M 1/ 1 r y �izo&-•2?S nc rlcmded i., �iW.r�'el �e,(�i.1Y, j�-{P'"Blie d wvA /iyT. <br /> Legal Description (as indicated on t�( statement) ;^Q A�aoF O��p16 L.'�` Q, ,SCt•y;'�,..4!/,-T yQ N /'W" ,e- <br /> Permit(s)Applied for: ��// !`/ U.KST, (3.•��e�f Ctf/- k¢.. O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Untt 0 < <br /> N <br /> AdditionPrivy Moving Subdivision o 0 <br /> v <br /> Structure Use: Z"I,� 0 0 <br /> (family home/cabin,garage, type of addition, etc.) m :JC <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). o <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 ordi- <br /> nary high water mark of lake, 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. ��^ k o <br /> PLOT PLAN <br /> ) �* f s ISO C,�j e Z (nY( <br /> / 150 o a <br /> cJ e 0 <br /> I e <br /> ORWYA <br /> I <br /> J. to <br /> x J <br /> \../ N <br /> O ^ / <br /> C7 <br /> q O <br /> f .l d r <br /> ,{ O <br /> FIEI z <br /> (( to MW (nr DDW � <br /> i v m a� am �n70 <br /> �1 0 "c0053 <br /> o zmi <br /> 2 <br /> N€ O <br /> o i ' � C <br /> : <br /> I declare that this application(including any accompao <br /> nying schedule)has been examined by me and to the best of my knowl- 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- $ 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. I i i a ': <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 per it county officials charged with administering county ordinances or other authorized person to have <br /> access to the above d cr a premises at any reaso le time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> signature of own wilding contractor) (date) ; o; ? o <br /> ZONING ADMINISTRATOR <br /> w -n <br /> TOWNSHIP PERMITS MAY BE REQUIRED u m <br />