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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> f <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 n <br /> tions of the tate of Wiscqnsip o <br /> � �,l Lie l 01011 e&- Pt �n�r\ <br /> m O <br /> OWNER(Please Prin Contractor or Surveyor or Agent n <br /> 9 9 W f�l'w s d <br /> Address Address <br /> SClrw. <br /> City,State,Zip Code City,State,Zip Code V 1 <br /> Ll ATelephone `? q&v el kTelephone <br /> wu, L\(4k"e R <br /> Emergency/Fire No. and Road l,Nr I l7 Iro <br /> �1 <br /> c <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied for. o <br /> New Building Sanitary Filling/Grading Camping Unit 0 ,<s <br /> m r <br /> Addition Privy Moving Subdivision g Q <br /> dam` tyn� � 1�7 o <br /> Structure Use: ° <br /> (family home/cabin, garage,addition,etc.) C <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. in <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. X <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. <br /> 71 rn <br /> PLOT PLAN / 04 o a <br /> <_ <br /> m o vJ <br /> C ro <br /> No, 1e <br /> wn <br /> m <br /> s <br /> ca <br /> I we\\ <br /> 1 � <br /> (sue/- po ( Ts +ivy l(jt�r�� <br /> 7o N�rAr DDWy <br /> .mm � a� m <br /> m n� '—o-m nn70 <br /> a e' MCoO5; <br /> Z w i z o J m <br /> Ty 9 <br /> I declare that this application(including an accompanyingschedule has en examined b me and to the best of m knowl- C, g` '• n 7 ' '• C <br /> PP ( 9 Y ) Y Y po? om , y <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informs- : � m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- g N G <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 abov described premi s at any onable time for the purpose of inspection. '• n~cl <br /> � N 0 <br /> Ce/t 1/a 0 <br /> SIGN HERE <br /> (si at re of owner r ilding contractor) (date) <br /> ZONING ADMINISTRATOR ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED SS88 o m <br />