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Burnett Qounty 2418 Co. Rd. K, 1102, Siren, WI 54872 Office of Zoning Administrator d _0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS . <br /> d 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 m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tionf the State of Wi consm. <br /> K <br /> P <br /> N-d-S .mm-- , y <br /> i r 7T1 C a <br /> jW_NER�(Ple a Print) �..�n Contractor or Surveyor1or1 Agenl��-,/?--� <br /> Z11Z--I1LL (fee , tiYl If[i `P� i� UIGZ 5 b 1,s m <br /> Ad"A0 -rte Address <br /> 0) <br /> City,State,Zip Cc City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition _ Moving 4 <br /> Sanitary Camping Unit o <br /> Privy Subdivision m <br /> 0 <br /> Structure Use: 01Cag2i /7C1C.77-( J � <br /> (family hometcabin, garage, addition,etc.) 0 v° <br /> 0 <br /> m <br /> Directions for plot plan drawing: ` <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)and indicate North (N). <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield (DF). r- <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. o <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. 0 <br /> 0 <br /> PLOT PLAN 3 N <br /> c <br /> Z a <br /> 0 a <br /> 3-3 <br /> I <br /> I <br /> n <br /> 0 <br /> 2. <br /> 0 <br /> n <br /> ZN <br /> Z <br /> O <br /> Z <br /> ^I D <br /> m c�W0 ncm <br /> n-.m <br /> 61dq Srlrl� Cd1� P2�mi� 1a3�� m <br /> ° : n C) <br /> 0: <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 0 m <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of allm <br /> n ; <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing a <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to theove described premises at any reasonab time for the purpose of inspection. <br /> VI <br /> J\ I T <br /> H <br /> SIGN HERE y, <br /> ( ' lure of ow r or building contractor) (date) o o <br /> o: o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMI S MAY BE REQUIRED V NN V OO m <br /> 0000 0 <br /> 0000 ooCA <br />