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On Com <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 o 0 <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 and m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- O <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. _ o <br /> //�/ / w <br /> ,C-T �L /1' 0 IS'e C 17 ,Cf�1 Y fly"{� /'O n-S cm <br /> O <br /> OWNER(Please Print //�� Contrktoorr or Surveyor or,Agent // o �' <br /> ) .�95 lM. r��/[/Jc� /}L' e. .Y / �als �i �Y LR,2C• <br /> Address Address <br /> /��i, t tc+r �k�� 04 lop-5.6 / O <br /> City,State,Zip Code City, State,Zip Code <br /> r <br /> 1411101 ,7• 5S/119 2,s9- 'l3br� <br /> Telephone Telephone J. <br /> Emergency/Fire No. and Road Name (� <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: O <br /> 0 <br /> New Building Sanitary FillinglGrading Camping Unit 0 <br /> r <br /> Addition Privy Moving Subdivision $ g <br /> y'^, v <br /> Structure Use: 1 /'� 0 6 <br /> (family home/cabin, garage, type of addition, etc.) ^1 <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. o <br /> 3 <br /> PLOT PLAN En <br /> .0 c <br /> 0 c <br /> � n <br /> _1 N <br /> / // 1`ON 0 <br /> 1 1 �VLt�Ef �`1 INie <br /> KK C <br /> vl <br /> P <br /> N <br /> \O ' 0 <br /> y 7 <br /> ee v IV <br /> l' <br /> IV^, <br /> w <br /> Z <br /> cr< O > 0 a_. m <br /> D G ' Cin 0 0 <br /> L'. 2 N 0 7 <br /> N <br /> G c[ Epi n[ c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- C1 0 i <br /> h A <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: G <br /> tion contained in this application(including any accompanying schedule)and I furtherdeclare that I recognize that this infor- ;a6 <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I :aa <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- A iw� <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have � <br /> o:v: <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m N: <br /> N <br /> SIGN HERE I, <br /> (sign r of owner or 'ding contractor) (date) o b : iu 0 <br /> ZONING ADMINISTRATOR �L`? /tel'/�ti O ! i o ,fD, o <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0000 ^. m <br /> 0000$ <br />