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Dn com (' <br /> Burnett Couhty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -.0 a o <br /> APPLICATION FOR — LAND USE — PERMITS - 3_ <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and �+ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 al <br /> tions of thptate of Wisco n. /Z o <br /> SA~ y�v <br /> OWNER(P ase Print Contractor or S rveyor or Agent n f <br /> �3a § -1 ��3y <br /> Address Address <br /> 9p�i.,s Alv 553(13 <br /> City,Statet Zip Co i _ o /00 X o�O city,State,Zip Code �. <br /> Telephone D o O Telephone <br /> Emergency/Fir and Road Nart)g� W 1i` ( %�/� <br /> 3(, i l� <br /> Legal Description(as indicated on tax statenlent) <br /> v <br /> Permit(s)Applied for. o <br /> New Building Sanitary Filling/Grading. Camping Unit 0 <br /> N <br /> Addition Privy Moving Subdivision o ^°r. <br /> v <br /> Structure Use: <br /> (family homelcabin, 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(NS)and indicate North(N). o <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. 1I <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. 9 <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 a V)PLOT PLAN See l �"U o n <br /> M (1A <br /> C ^' IT <br /> s <br /> t SSIOw C2N.� a <br /> '1 ( t4u (u 2 5ree, N l b 3 <br /> ru6t -�' kjc remo"ec; "�cV7 Ppl2rcv <br /> Oq io <br /> Get <br /> � a <br /> riaA.'�¢Iwa�' 61- wc� <br /> o <br /> N <br /> ff w 1� <br /> /Uc,� araue(eeQ a,,.e <br /> f <br /> 9 UI�N DDmy <br /> m M�*_ Osag <br /> a < i 1 w .m3 <br /> w <br /> M <br /> I declare that this application(including an accompanyingschedule has been examined b me and to the best of m know]- g` m <br /> PP (� 9 Y ) Y Y o f i <br /> edge and belief it is true,correct and complete.I acknowledge that I 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- ; H r; O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I P! <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. E »o <br /> V NF: <br /> SIGN HER <br /> (sig a of owner or bui ing contractor) (date) <br /> q $ <br /> ZONING ADMINISTRATOR �'� <br /> TOWNSHIP PERMITS MAY BE REQUIRED N T TNOO m <br /> $$$$$$$m <br />