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ark c o m <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m M a o <br /> APPLICATION FOR — LAND USE — PERMITS3' <br /> N 0 <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- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 OR 41 <br /> tions of the State of Wisconsin. �' o <br /> OWNER Please Pri, .� Contractor or Surveyor r Agent n F <br /> Addr ss Address �? <br /> t abs'CK <br /> City, State, ip Code City, State,Zip Code v <br /> Telephone Telephone , 0 <br /> Emergency/Fire No. and Road Name (�n� <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for: G> <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition X Privy Moving Subdivision S <br /> Structure Use: �� k_,i ( l;�2 k I`I-/ <br /> (family home/cabin,garage,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). -� o <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield(DF). \ .1 <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. V" <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 0 0 <br /> the owner. 0 <br /> on 3 n <br /> PLOT PLAN on o a <br /> M o <br /> � o <br /> I <br /> t 0 <br /> 0 <br /> 0 <br /> o <br /> r <br /> &o <br /> �U�rSO 76P-`/n <br /> C 3 a 9 <br /> �c wm p3 c <br /> Z o: Z : � <br /> m=t E y <br /> m <br /> i7 o ii D <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o $ 0 <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- <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. O^ <br /> m m <br /> SIGN HERE <br /> (s' ure of owner o b ilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> �� in in`min inwin-t <br /> TOWNSHIP PERMITS MAY BE REOUIRED N N O N U m <br />