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Oc\ CC' cyl 1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratoro a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shownherein.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 n <br /> tions of fie State of Wisconsin. m o <br /> N v <br /> C <br /> o N �/Oy )4 !?_ )-e),44 <br /> OWNER (Please not Contractor or Surveyor or Agent . 3i <br /> V <br /> Address Address <br /> N XiCKL. Y Mrl . T5_03 -7 t <br /> City, State,Zip Cod City,State,Zip Code <br /> Cle 12) Ly– 10 9- <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> �—= I ? .PQ-RDtl,vs IQ L,,-,C 12"ES JAK16NL) S u.' %y AleZy ScC.'7 A40V 16t•i1 <br /> Legal Description(as indicat on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> r l/ <br /> Addition Privy Moving - Subdivision <br /> C i4 13 fv 3J <br /> Structure Use: Z <br /> 0 a <br /> (family home/cabin, garage, type o 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). <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. O <br /> 0 <br /> 3 <br /> PLOT PLAN 'R <br /> N <br /> Z c <br /> 0 0 <br /> n <br /> 0 <br /> / O <br /> O <br /> / I <br /> t r'� <br /> to <br /> __...._. _.._. -. <br /> O LH oR. <br /> N c �N <br /> ��y✓ <br /> To GG yTf I <br /> z <br /> X9 /Jr f A <br /> 4t "OW <br /> m c M.w w o c <br /> v <br /> o < 0 0 0 <br /> aW <br /> I declare that t s application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- c o 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 � 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 permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the abo described premises at a y reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE <br /> I�ryatur of owner or building contra tor) (date) o <br /> FLOW I <br /> ZONING ADMI STRATOR o. <br /> o <br /> iJNOIJ � N <br /> TOWNSHIP PERMITS MAY BE REQUIRED o `" <br /> 00000 0 <br /> 00000 0 <br />