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61-) cC1,J) f' <br /> Burnett Cbunty7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning AdministratorA o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> s <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- 3 a <br /> tions of he State of Wisconsin. m <br /> A I' �i �S� � C <br /> OWNER(Please Print) Contractor or S ey r Ment <br /> Addr ss , i � V�, . 54�^(ill'� Ad res S � <br /> I��Lc?-^✓•- <br /> City, State,Zip Code City, State,Zip Code <br /> C� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o C <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: 0 0 <br /> (family home/cabin, garage, type of 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). 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. n <br /> 0 <br /> 3 <br /> PLOT PLAN o <br /> rn I/ ^ <br /> Z c \ <br /> 0 Q <br /> n <br /> p_ J <br /> u, <br /> C3 0 <br /> a <br /> N <br /> 0 <br /> ` Z <br /> /1 <br /> m c�ww nac� m <br /> 5j'5: <br /> co: M <br /> G n' m <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 ;4 a <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 premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> df <br /> SIGN HERE <br /> (signature of owners or building contractor) (date) <br /> ZONING ADMINISTRATOR7't1 <br /> J N N O N 8—" m <br /> Vt <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 P ON m <br /> 0000000 Vl <br />