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o <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c ; a o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> ° f <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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. p <br /> —/Ch Cc /7%h �LF✓y /�iu¢LL��li <br /> OWNER(Please Print) Contractor or Surveyor or Agent n E <br /> r//.�C ST7;✓SNS Jam. S : a Oil/� m <br /> Ad is Address �? Oi <br /> /Glc Fi.�LO � vY1,+1 �:_5�•3-�, rr� I <br /> City,State,Zip Code City,State,Zip Code v, <br /> 1 I <br /> Telephone Telephone .� <br /> Cai'�; -R(o9- v3 as <br /> Emergency/Fire No.and Road Name V <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied fo <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision 0 <br /> \ Y <br /> Structure Use: Qr� <br /> (family home/cabin, garage, addition,etc.) 3 D <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 G <br /> 2. Show the location of the well(W),septic tank(ST), and drainfield OF). <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. Mill <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, c <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 by O n <br /> the owner. y.I 0 <br /> PLOT PLAN \-�QJY S2'Q.. t✓11� }r ( IZ C` �I a N <br /> u � z `v <br /> J (7 o n <br /> m a <br /> C <br /> N = <br /> �t <br /> Lr,T <br /> �}f�u 5H �PA KJ �R�AG r �S dco <br /> y Ir_�p c9v y a-- <br /> INo <br /> f <br /> N c M.N 0 OO a a m <br /> 9 00 <br /> m : `Zmo 0m _ <br /> _.�.` a o' <br /> _ mm' S <br /> Y <br /> �2 <br /> : m <br /> L)0 C <br /> 1 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 informs- O�i : m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- ,C E g y E O <br /> V N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I r., <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- V-' <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. i n o <br /> T 3 m <br /> m <br /> N <br /> SIGN HERE � � <br /> ( ' net re of owner ilding contractor) (date) ' o <br /> $ <br /> ZONING ADMINISTRATOR ' `• [ i <br /> TOWNSHIP PERMITS MAY BE REQUIRED ��U NN000m <br />