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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 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- <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 /> y w <br /> Mar11 N Noz SAtJ l_:�c_�ct5oJ (1oN �1 <br /> OWNER(Please Print) Contractor or Surveyor or Agent n £ <br /> ag ��► �,��-rr;4u way � �� <br /> Address Address (1 \ <br /> City,State,Zip Code City,State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permits)Applied for: n O (�• <br /> ° N <br /> New Building Sanitary Filling/Grading Camping Unit 5 `- <br /> Addition - Privy Moving Subdivi n $ ^°r. <br /> Bed�2«om��lr � i snc� t��lwal <br /> Structure Use: 0 0 <br /> (family home/c bin, garage, type of additi , etc.) 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 OF). 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 /> 3 <br /> PLOT PLAN /� P y <br /> Z c <br /> lod y o n <br /> N <br /> 1 O <br /> 1 Lr( <br /> I <br /> C) <br /> �,&)f <br /> C7 I' <br /> 3L Niw a <br /> 0 <br /> D � <br /> fi <br /> JJ mvCID r 'D in V <br /> C o a< 30oa <br /> lass t k o <br /> y: 9 <br /> m <br /> D <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i y <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- Ao 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 <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 /> +lication.I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> ,.cess to the above descri ed premises at any reasonable time for the purpose of inspection. <br /> T <br /> QN <br /> HERE _ V �3 <br /> ( ' ture of own or building contractor) (date) o o <br /> i ADMINISTRATOR <br /> (Q n <br /> �/ cNii voiN o <br /> TOWNSHIP PERMITS MAY BE REQUIRED m 0000' o m <br /> 0000 o Vl <br />