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$11 (9149 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m � o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> o <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. mc <br /> nett County Land Use Ordinance,Sanitation Code,and with all other pplic le County Ordinances and the laws and regula. 3 n <br /> tions of the State of Wisconsin. / m <br /> (/u O <br /> OWNER(Please Print) raAorX Survevorror A t <br /> /71,0 N. Q41-'4o, /T 5.7 <br /> Address �/ <br /> _ S� / f�GlL /Jit/ ✓.`7��7 ss <br /> City,State,Zip Code City,Stade ip Code <br /> i-4 — 77 <br /> Telephone ..aC/ter•'• Telephone <br /> Emergency/Fire No. and Road N me <br /> GOT 3 CS�1 1�8 e.. <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: 3 O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit <br /> u <br /> Addition , Privy Movi Subdivision 0 -or„ <br /> Structure Use: �a ��d� �� o d <br /> o <br /> ,ffarnify-home/cabin, garage, type of addition,etc.) <br /> Wthe <br /> n 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.,thepl st be signed and dated by <br /> the owner. n <br /> 0 <br /> PLOT PLAN3 <br /> N <br /> Z c <br /> o Q <br /> n <br /> o <br /> 30, <br /> CY d <br /> 0 <br /> 3 <br /> 0 <br /> VJ Z <br /> 9LIA14 r4/vk <br /> / 7o my Nr DDmy <br /> m c �.mm mac m <br /> a 0womn3 <br /> N `2 N O �(O <br /> C <br /> of <br /> I declare that this application(including any accompanying sc edule)has been examined by me and to the best of my knowl- 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 informs- ' 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 -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 de cribed premises at any re onable time for the purpose of inspection. <br /> SIGN HERE ' <br /> (signaturof owner or building contractor) <br /> o. a <br /> 'ONING ADMINISTRATOR o <br /> cL � T <br /> TOWNSHIP PERMITS MAY BE REOUI m� 3 0 " 0 o0000o m <br /> i <br />