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o yl co") <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d _ 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d <br /> 0 r <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and rn r <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other plicable County Ordinances and the laws and regula- 3 <br /> tions of the State of Wisvnsin. o <br /> � cC <br /> OW ER Please,Print u n cy O <br /> 9( ) �/)E Contractor or Surveyor or Agent f <br /> �5i Li> d <br /> A / n/�rJ `I Address <br /> c�y7fF 70 <br /> City, State,Zip Code City, State,Zip Code <br /> _5 <br /> p, <br /> Tele h ne <br /> 6 _ _ fM3 Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) p <br /> Permit(s)Applied for: <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit Z <br /> AdditionPrivy Moving Subdivision w o <br /> - 1� <, �a rl "� <br /> Structure Use: z <br /> (family home/cabin, garage, type of addition, etc.) o � <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 lank(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. <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 /> PLOT PLAN 3 <br /> a <br /> Z c <br /> o Q <br /> a <br /> —� y <br /> OQ <br /> it <br /> � e <br /> ' -� ^JAL ` I 0 � <br /> fir__ <br /> r <br /> o r : <br /> t <br /> ,O// 0 <br /> 7 <br /> y C � <br /> t <br /> D <br /> Q <br /> j �r]L �C� o U< = 00 '=sm <br /> z us <br /> —.. 42 <br /> m i <br /> O j 42 <br /> S n — ------ <br /> ._7P m <br /> ! C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> C, o: ; ! y <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 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. Ia <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 pre5jises at any reasonable time for the purpose of inspection. `,• <br /> m V <br /> SIGN HERE I- ( d' m <br /> (sig u f owner o ding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> C�cNn <br /> TOWNSHIP PE MITS MAY BE REQUIRED ron <br /> 000b <br /> 0000g�o. <br /> �b <br />