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On CC;in� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - o o <br /> APPLICATION FOR — LAND USE — PERMITS 3 f <br /> d = <br /> a <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- <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. <br /> io m <br /> •-1'Lr16( l l /SLY V(f r t .f' �.; yi yl/y.�✓ a O <br /> (Please Prin r Contractor or Surveyor or Agent o <br /> Address <br /> C, State, ip Codes cityyst ta, Code <br /> Te h0 Telephone <br /> �i r�P it t✓ <br /> Emergency/Fire No.and Road Name <br /> L(!' „k s M l%/,v 'n e (p /k7 J:2 62fi' 14)1' �7 2 -ie -/5� f_ <br /> Legal Description (as indicated on tax statement) <br /> Permit(s)Applied for: .��. O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit 0 <br /> Addition Pr'vy Moving Subdivision o <br /> Structure Use: )�� 1 P1��Nb o 0 <br /> (family home/cabin, garage,type of addition,etc.) <br /> Directions for plot plan drawing: <br /> w <br /> 1.Show the location and size of all existing buildings(EB)and all new buildings(NB) and indicate North(N). is <br /> 2. Show the location of the well (W), septic tank(ST), and drainfield (DF). 91 <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. O <br /> 0 <br /> 3 <br /> PLOT PLAN <br /> 9 n <br /> o Q <br /> N <br /> O <br /> 1 0 <br /> e <br /> 0 <br /> 0 <br /> _ <br /> rZ) <br /> � Z <br /> 14) <br /> m c�wwn cm <br /> m <br /> Qo: o C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- oii y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- CQ' ; o 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 couRty officials charged with administering county ordinances or other authorized person to have <br /> access to the above des r d pliermses at any reasonable time for the purpose of inspection. <br /> T <br /> m <br /> N j <br /> SIGN HERE '� y�/ —,— Ste— I in <br /> (s' lure of ow Ing contractor) (date) o $ <br /> ZONING ADMINISTRATOR ron r, <br /> TOWNSHIP PERMITS MAY BE REQUIRED. p <br /> 00000 0 <br /> 00000 0 <br /> T�11/fir � ��c NOV 11989 <br /> STAB yc <br /> 7S ` 70 /Ok,'N �.cX�l - 10/'t,e:•-'�r(/t�fpb'Grga-t <br />