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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator m � 0 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 <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 the State of Wisconsin. O t <br /> rn v <br /> N <br /> JIOLA hul- Kotj 5 ctLl o <br /> OWNER�PIeas Print) C C ^,T Contractor or Surveyor or AgentRt <br /> 0 <br /> A <br /> Addres U Address <br /> j�Q <br /> City,State,Zip de City,State,Zip Code ( Q <br /> Telephone Telephone " <br /> l <br /> Permit(s)Applied for: <br /> New Building Filling/Grading C <br /> Addition Moving o <br /> Sanitary Camping Unit n o <br /> 4 +vim <br /> Privy Subdivision 0� <br /> m r <br /> o � <br /> Structure Use: � v <br /> yarn y homeicabin,garage,addition,etc.) o v <br /> m <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. (,a 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. QM <br /> 5. If,separate plans are submitted yyan architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6. Provide legal land description. <br /> PLOT PLAN o <br /> 9 y <br /> c <br /> Z a <br /> 0 <br /> C-2) 00 <br /> n <br /> 5� as Sscgo � z <br /> f\1 � <br /> o <br /> O s <br /> O <br /> 11 , Z <br /> C <br /> W <br /> 0, a man 7G <br /> fik {� w� Yts ✓—(I 5fi / ' <br /> av Qv,4y No o03 <br /> H � .m _ <br /> o ' O <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my —ET: <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I reco nize that A ' O <br /> PP (� 9 Y ) 9 p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a '1 o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> 1 <br /> SIGN HERE <br /> (sig urof owner orb 'd' contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> (7' <br /> N N o N p. N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED (DQaa�o m <br /> 0000 00 <br /> 0000gooVl <br />