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of--� Osx A V <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Em o 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 ICJ <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 the State of Wisconsin. <br /> o <br /> N d <br /> yl Somm e <br /> a o <br /> OWNER (Please Print) A y 'tContractor or Surveyor or Agent <br /> 4 F <br /> - — 's _ S Q M Z I ld1 m <br /> Address Address <br /> 13� a ] 0 , MN .55 : 13 Sg1n1e � <br /> Cit ,State,Zip Code City, State Zip Code <br /> Ljfa- _5 c--., <br /> Telephone TelephPne <br /> f e n (,( oc� cess 57co m La es o �, <br /> EmergencylFire No.and Road Name f 6) <br /> Legal Description(as indicated on tax statement) <br /> e�,st2ah.� <br /> Permit(s)Applied for: ,00., 0 <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivision o <br /> Structure Use: Cc, f n o 0 <br /> (family homelcabin, garage,type of addition,etc.) -/ <br /> 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). Q. <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). r--. <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. �1 <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 f <br /> 3 <br /> PLOT PLAN o N <br /> !�J '—/r yf Z c <br /> N <br /> T (r, LP <br /> � J <br /> o <br /> J <br /> �! <br /> o I J I ro <br /> U <br /> Un <br /> 'eA CL <br /> P1111", <br /> l� t' <br /> J oo c°ddaas° m <br /> I m n� �ny aa � <br /> Tu <br /> r' <br /> GV N O 0. i <br /> rid/ I C. ".' v',: { =:� m <br /> - Scott, Lot i_ Cie '0 : o <br /> 0 10: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o :c�J : y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- �" $ 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. 1 ' :tea <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'reasorkjWige for.aVurpo;a Of inspection. <br /> T :N1 <br /> ( c N <br /> SIGN HERE ' it 'J L96 � mim :A <br /> (s' n of w i contractor) (date) <br /> o: <br /> ZONING ADMINISTRATOR ` -"""'�• • Sy S <br /> TOWNSHIP PER ITS MAY BE REQUIRED O . �So9S fmA <br />