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Can C cf-1J <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,� m a 0 <br /> ' APPLICATION FOR — LAND USE — PERMITS 3. 0 _ <br /> 0 <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- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> lions f the State of Wisconsin. <br /> '��J�, W <br /> roll �• �=�� �UL�6 �'ane_� ` <br /> n O <br /> OW R(Pie se Print) Cont ctor or Su eyor or Agent o <br /> . 1 ,R( 7 0 <br /> Add����e� Add is _ R� <br /> �2n Int i J_fa � -�-- <br /> City,State,Zip CodCity, State,Zip' <br /> Code <br /> W 0 <br /> Telephone Telephone t 0 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) f <br /> Permit(s)Applied for: 0o SWI <br /> New Building Sanitary Filling/Grading Camping Unit m +J/, <br /> Addition Privy Moving Subdivision o <br /> v <br /> Structure Use: 0 0 <br /> a <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). 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. o <br /> 3 <br /> PLOT PLANz <br /> o Cr <br /> a <br /> La: <br /> / + ' U\��/T �\/• J OQ N <br /> V <br /> P. <br /> �o� �*7 J Z <br /> o � <br /> N <br /> 0 <br /> N <br /> 0 <br /> N � <br /> Z <br /> I33 <br /> I <br /> M cM.mm aaccm <br /> 0 a< J J 0 a-' m <br /> V < ' dCNOJ ; <br /> FA, , A O J m <br /> Z O .2 1 <br /> J u) <br /> v cz m <br /> o o C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- <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 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 /> T <br /> N <br /> A <br /> SIGN HERE <br /> (signature <br /> `� of owner or building con^trtor) (date) <br /> ZONING ADMINISTRATOR <br /> n -1 <br /> N N O V N m <br /> (TN(P(nOOUt <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 00 o c o o m <br /> 0000000fA <br />