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o(\ COAn - <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� m 0 0 <br /> APPLICAT\ON FOR — LAN1D VSE — PERMITS ' 3 ❑ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. (� <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. m o <br /> 2Q2±9r � / /� G/l/f ///'/ � t'J' ) ii '� <br /> OWNER(Please Print)LL Contr— a�t rurveyor or Agent p <br /> Address Address 1 <br /> City, tate,Zip Code City, State,Zip Code <br /> .,telephone �1 l Telephone <br /> Emergent /Fire No. and Road Name <br /> �D l' S/>/1 <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: 0 ^ <br /> o L <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: Z <br /> 0 <br /> (family home/cabin, garage,type of 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). <br /> 2. Show the location of the well (W), septic tank(ST),and drainfield(DF). r <br /> 0 <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. 0 <br /> 0 <br /> 3 <br /> PLOT PLAN o <br /> y <br /> 0 c <br /> o a <br /> T. <br /> / 0 <br /> 41- Pr'lq <br /> 5V -��' <br /> ) <br /> C 0 <br /> s <br /> I z <br /> a <br /> /fes` <br /> ii-- <br /> r/trDDWm <br /> LD. a am =a � <br /> cHo=' 3 <br /> N N O 3 m <br /> Z O <br /> m <br /> o: C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowk o <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informa- o m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor. o G <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I a <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, <br /> m <br /> m <br /> SIGN HERE <br /> (signs re owne r buil contractor (date) o\ o' o <br /> ZONING ADMINISTRATOR ` o: E o <br /> o: o <br /> T <br /> N N N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED ��u, m <br /> 0 0000m <br />