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7410 Co. Rd.K, #102 <br /> Siren, NI 54872 <br /> Burnett County Office of Zoning Administrator d710 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> u o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 6 „ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m f� <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. p <br /> OWNER(Please Print) �^^� Contractor or Surveyor or Agent ' i F <br /> �c�( Rt 1 lJX F)I 7 m <br /> m <br /> Addr t^ Ir Address <br /> City, ' <br /> te,Zip oe/ Yt✓ 1 J City,State,Zip Code � �^ <br /> Telephone Telephone e1, <br /> Permit(s)Applied for: } 4J <br /> New Building Filling/Grading 1, <br /> Addition Moving o <br /> Sanitary Camping Unit ) <br /> 0 <br /> Privy Subdivision 0 <br /> [\ y n <br /> Structure use: <br /> (family licimelcabin, garage,addition,etc.) o 0 <br /> m 1l" <br /> Directions for plot plan drawing: �� I .� <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). Al <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-it within 1000 ft. and the location of any river or stream - if within 300 ft. 0 <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, <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 <br /> the owner. <br /> 6.PLOT PLAN Provide legaldescription on a side o is form) O <br /> as on ax statement. 3 <br /> 'P 0 <br /> Z a <br /> o n <br /> o <br /> I <br /> 0 <br /> O <br /> C <br /> m <br /> O <br /> O <br /> » T n <br /> N <br /> 7j <br /> I a <br /> 73 Z <br /> I D <br /> �l <br /> M c m w>n a)-a <br /> m[ `2 00� <br /> Z o: <br /> ' ° <br /> pp "` 2 m <br /> l�P, n : : lo <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> PP (including Yaccompanying ) g � : <br /> information contained in this applicationan schedule and I further declare that I recognize that a : m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above describe premises at any reasonable time for the purpose of inspection. <br /> T <br /> S <br /> N <br /> SIGN HERE ` ` ti / o <br /> (s' Lure of owner pf building contractor) (date) v E E N <br /> `, / <br /> ZONING ADMINISTRATOR J /Ty <br /> TOWNSHIP PERMITS MAY BE REQUIRED Nn^n N o o N m <br /> 0000000CA <br />