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I 11 ; i i /':;. <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d71 i o <br /> - APPLICATION FOR — LAND USE — PERMITS 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and71 0 <br /> 6 <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- <br /> tions of the State of Wisconsin. m o G <br /> / / / N <br /> OWNER(Please Print) Contractor or Surveyor or Agent m m <br /> ism f n R <br /> A <br /> ITf�Qtast resl� Address <br /> City,State,Zip Code City,State, Zip Code <br /> 7 iS• 7 <br /> TelephoneQ r' /�,, n y�Tellephone .J. <br /> aq I c� 1 Iv,"Clux(UX�v� K-Al i <br /> T <br /> Emergency/Fire No. and Road Name- � <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision g 0 <br /> Structure Use: o 0 <br /> (family home/cabin, garage,type of addition,etc.) <br /> r <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. n <br /> 0 <br /> 3 <br /> PLOT PLAN a <br /> ur <br /> Z c <br /> o a <br /> V 0 <br /> . I O <br /> 1 f <br /> (p a IIIc` <br /> 0 1\ <br /> I R N <br /> m <br /> 0 <br /> f1 0` <br /> �t J <br /> N <br /> 0 <br /> 0 7 <br /> y � <br /> 6` � S Z <br /> ri <br /> X p/v(nr DDa) ' <br /> p c a 0 00 n c <br /> m a< J-'nm any <br /> 2 0MQ3 <br /> 0 '; 0 J�n <br /> o ' ' rn y <br /> m <br /> Tn 2 <br /> CA o E C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know]- ,.,[o: J : S <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- O C <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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 /> p�e A <br /> SIGN HERE R , / y <br /> (sig atu of owner ding contractor) (date) <br /> o: o <br /> ZONING ADMINISTRATOR <br /> y n <br /> TOWNSHIP PERMITS MAY BE REQUIRED g' 0 8 S vmi <br />