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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> W ° <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- <br /> tions of the State of Wiscon in. m O <br /> C��Y� l/ _eSSCP �a�1'� I'�Y c�l�S2_ <br /> w w� <br /> O <br /> O NER(Please Print) Contractor or Surveyo or A ent n F <br /> C Lct a1� Z(P LA S �a r,d P+� � d <br /> Address Address <br /> MC) <br /> =° ) <br /> C-l) I <br /> City,State,Zip Code City,State,Zi Code <br /> C0 (D L4 C? <br /> Telephone Telephone <br /> Emergency/Fire No.and Road Name (� <br /> Legal Description(as indicated on tax statement) 0 <br /> Permit(s)Applied for: o 0 <br /> New Building Sanitary Filling/Grading Camping Unit <br /> m r <br /> Addition Privy Moving Subdivision 0 o <br /> Z a <br /> Structure Use: c j q <br /> family home/cabin,garage,addition,etc.) S. <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). o <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. '11 <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, Q <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 byO O <br /> the owner. o <br /> 9 co <br /> PLOT PLAN Z c <br /> C5 <br /> coo ' <br /> mil <br /> d. w <br /> a <br /> l � <br /> oo <br /> r IUB <br /> w <br /> r <br /> Z <br /> I <br /> G <br /> M p»rnr DDmy <br /> aam <br /> Q N p m ; <br /> mmE <br /> G^g[ G)oE A <br /> n [ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <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 <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 EG <br /> access to the above described premises at any reasonable time for the purpose of inspection. T i� r o; <br /> R � 9 NFA <br /> rp N N (T <br /> SIGN HERE��//�? / l9 6 w g <br /> V: <br /> (signature of owner or building contractor) (date) o <br /> o: <br /> ZONING ADMINISTRATOR i <br /> in:n�'in in in in m <br /> N NON��tTm <br /> TOWNSHIP PERMITS MAY BE REOUIR D n m v O o o m <br /> $S$$SS8fn <br />