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01 ) ( UI f ) t <br /> Iturnett-County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator _� o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d <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- J <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. o <br /> /in,d7isr� SA C m <br /> OWNER(Please riot) Contractor or Surveyor or Agent S F <br /> 7c 'Ty „Z,�yo Aut So <br /> Address Address N <br /> �/cNriELl1 rhn/� SS yd 3 , <br /> City,State,Zip Code` City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: n <br /> 0 <br /> New Building X Sanitary Filling/Grading Camping Unit <- <br /> N <br /> Addition Privy Moving Subdivision a 0 <br /> S?oRA�E ..ate loY�y i �c� � ' w I� Jb' 3g Z 0 <br /> Structure Use: 0 'o <br /> (family home/cabin, garage, type of addition,etc.) m <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). o <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. n <br /> 0 <br /> PLOT PLAN c p <br /> a �0 <br /> J <br /> Z <br /> - � a <br /> AU14A6E <br /> M c�w N 0 a a m <br /> n a< > > 0a-. m <br /> 1 mv a� =am =a M <br /> — ._ v_i[ •gym o �r0 <br /> d m <br /> IIVWI�7' .4 Ale <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o S: ,`-',o o 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- t✓ ; ; m o o; m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation :.a0om <br /> ! <br /> 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 Count of Burnett relying on this information I am providing in this a "'^' <br /> P Y Y Y Y� 9 P 9� P- j :�,.. <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 /> SIGN HERE - e VA14 P" ,n a. <br /> (sig of owner or byil g contractor) (date) o`3: ;oo <br /> ✓✓ o a i :0 <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 000 <br /> 00o fA <br />