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Cif) C) I-) ) � <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator U � 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d 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- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> lions of the State of Wisconsin. o l.1 <br /> SFL F 3 (/ <br /> o <br /> OWNER(Please Print) Contractor or Surveyor or Agent n f <br /> L F�Y�� SoN � 'm <br /> Address Address <br /> o r3oX 3 8' ( <br /> Citytate,Zip Code City, State,Zip Code <br /> � W7,5 &Okrn k)" S Va Yo OQ <br /> Telephone ,/ Telephone <br /> 7�3- 7-11'12— <br /> Emergency/Fire No. and Road Name T C> <br /> "61'?MAc/c , /?D. -Y <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: n o <br /> New Building X Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision o '°r. <br /> __.c <br /> ^„ <br /> G9 PA6 F �i� X Zj [ z <br /> Structure Use: ° � <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). <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. <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, C r <br /> river or stream, if applicable. 'A <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by I <br /> the owner. 10 <br /> 71 3 m <br /> PLOT PLAN71 z c <br /> o a <br /> M <br /> m S 5 <br /> N <br /> r : <br /> I <br /> _o <br /> � G <br /> o <br /> o m <br /> m <br /> p <br /> 0 <br /> _ p <br /> p IV <br /> m <br /> o i <br /> w <br /> z <br /> M <br /> M mvmr>>W-0 <br /> 0 no <br /> m n� '-cm say <br /> 7'y: m <br /> _ _ m <br /> Ln$ <br /> c'>3': O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know[- cf i oA <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 0=2 : - S m <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- i H g"i G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I i i `-a w N <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- $a $ <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. S O»o <br /> m E 3 a : <br /> SIGN HERE L w <br /> (si of owner or b ' contractor) (date) <br /> ZONING ADMINISTRATO <br /> N NON��fTm <br /> TOWNSHIP PERMITS MAY BE REQUIRED u,v,p�"a Pm <br />