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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U 'ao 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 � m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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. <br /> C,yu�,� 1312 poKSf/'.9. lx/ Se�� <br /> OWNER Please Print) Contractor or Surveyor or Agent n £ <br /> �C? x y ad d <br /> Address Address :? <br /> Gti ED'S/�TLr L✓ll. S`t�/ r�93 <br /> City,State,Zip Code City, State,Zip Code I <br /> Telephone Telephone <br /> Emergenty(Fire No. and Road Name <br /> HS /O 6/LEf 0G <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: 0 o <br /> New Building Sanitary Filling/Grading Camping Unit o .`.- <br /> N <br /> Addition Privy Moving Subdivision <br /> �— z <br /> v <br /> Structure Use: C / el <br /> (family home/cabin,garage,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). i/1 <br /> 2. Show the location of the well(W),septic tank(ST),and drainfield(DF). IVI' <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 lake, 0 <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 O a <br /> the owner. <br /> 71 o ur <br /> PLOT PLAN - z `v <br /> o a <br /> M o=� <br /> a w : <br /> V' p <br /> 6p, O m <br /> j� o V/ <br /> _ <br /> VQ <br /> s <br /> m <br /> o � <br /> w I�vr <br /> I <br /> Z <br /> C � <br /> 1 � <br /> D rnvfprDDm-0 <br /> m c =.mmo o.cm <br /> a m ? No aro ; <br /> DE�� c s 41rz _ : <br /> !A. T2 i cm <br /> �� € <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- m ' <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- 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 `�'• ` '• ? v' <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 above described premises at any reasonable time for the purpose of inspection. :' O.. <br /> m n <br /> SIGN HERE <br /> N O; <br /> gn lure of ow building contractor) (date) <br /> o: <br /> o: <br /> ZONING ADMINISTRATOR i <br /> win�in in in inT <br /> NNON��(Tm <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br />