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01 -) C-CO) j <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator cr M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> 0 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> w <br /> located as shown 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- <br /> tions of the State of Wisconsin. o <br /> DRIeQ f L 17. 30 D/rE.V Je I <br /> OWNER(Please Print) Contractor or Surveyor or Agent n <br /> 916 o �a ffYe .UD. d <br /> Addrs Address <br /> m <br /> greJD/l�.yN %.g11/l� HV SSy</S <br /> City,State,Zip Code City, State, Zip Code <br /> CQ12- NZ S-�{p$d <br /> Telephone Telephone <br /> 2 reS5 5 a� sem .-ase-e 10—It <br /> Emergency/Fire No.and Road Name (�1 <br /> O 0 <br /> Legal Description (as indicated on tax statement) o <br /> m <br /> Permit(s)Applied for: � <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 6 <br /> N <br /> Addition Privy Moving/ Subdivision 0 <br /> /k <br /> Structure Use: Cabin — l.lUln� &.C,% la ' /y� 0 0 <br /> (fami home/cabin, garage, type of addition,etc.) <br /> r <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. <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. n <br /> 0 <br /> PLOT PLAN R m <br /> Z c <br /> P <br /> /ve R rf/ iC i PPse�`f peke iPd a <br /> t <br /> o <br /> rJ <br /> See 'perm�f 13 cis c0 <br /> I <br /> 90' �Ur SAr r QCn <br /> 0 0 <br /> 235 0 <br /> w � <br /> EAIst 26 <br /> 31 Caa�y X34• Z <br /> a , <br /> 0 <br /> 76 mymr DDW � <br /> 'y11,y� 0 c M.m 0 o ac <br /> a� Z m CL= ...a w <br /> m � m 00,n <br /> Z <br /> 0 E .2 : E 1 <br /> may: : 9 <br /> LyPaHe ";9:' m <br /> moo : O <br /> Oi <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowk O o: Ic,0 o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- p o' G m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- :ate <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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have j <br /> access to the above described premises at any reasonable time for the purpose of inspection. 'o <br /> N <br /> SIGN HERE <br /> Win: :pn <br /> (si at re of owner r wilding contractor) (date) o W : m <br /> ZONING ADMINISTRATOR l,o <br /> 44 T <br /> TOWNSHIP PERMITS MAY BE REQUIRED "� m <br /> $00000Vl <br />