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,;At Coupy 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator <br />APPLICATION FOR — LAND USE — PERMITS <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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 taws and regula- <br />tions of the State of Wisconsin. <br />D08 till 04:T <br />OWNER (Please Print) <br />FIQZ <br />Address <br />1jX8MR W1 <br />SHQ3 <br />City, State, Zip Code <br />Telephone <br />Emergency/Fire No. and Road Name <br />Legal Description (as indicated on tax statement) <br />^Iletierl de- 40PVIP_S <br />Contractor or Survepr of Agent <br />'' ]CSS( ��►� 3 S <br />Address <br />WZ85_TZ12 " <br />City, State, Zip Code <br />Telephone <br />Permit(s) Applied for: <br />New Building Sanitary Filling/Grading Camping Unit <br />AdditionPrivy Moving Subdivision <br />Structure Use: �� I �� A Obf V <br />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). <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. <br />PLOT PLAN <br />Ste- ft(t rA cKCo <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- <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 <br />access to the above described premises at any reasonable time for the purpose of inspection. <br />SIGN HERE <br />ZONING ADMINISTRATOR <br />ure of ownprp'Y building contractor) <br />U <br />TOWNSHIP PERMITS' '�Y BE REQUIRED <br />/ty Ove <br />(0 IL -'31 <br />(date) <br />T <br />0 <br />f <br />0 <br />r <br />O <br />0 <br />0 <br />r <br />v <br />0 <br />01 <br />M <br />0 <br />c <br />Cr <br />a <br />0 <br />W <br />0 <br />a <br />(D <br />n <br />O <br />I� <br />M <br />c <br />CL <br />0C.mm <br />a <br />ma <br />a <br />3 <br />N <br />O 7 tG <br />OZ <br />m <br />$: <br />0 C <br />Oo: <br />A° <br />m <br />m <br />m <br />j <br />O: <br />O <br />v+ �1 <br />cn cn yn pI <br />Nm <br />O O 9, <br />SS$o$oon <br />