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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m a o <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 v m <br /> located as shown herein.The undersigned agrees thaball work shall be done in accordance with the requirements of the Bur- (D m �l <br /> nett County Land Use Ordinance,Sanitation Code, d with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. <br /> rn m <br /> AM\:YI.�Cft�..) �-�w.>3 � Cu � �.-r.xt�: F WCtc�✓te�. cicj e n'f' � =? O <br /> OWNER(Please Print) Contractor or Surveyor or Agent ° :En.0. ('x <br /> 9T 1 Gt'y_Ig (A m <br /> Address ei Address <br /> lY+^^a."'i2a;v W L'S�• � i—rccic v mac.�.hl iSt- n s .-, �4�3� S I <br /> Ci ,State,Zip Code City,State,Zip Code LA I <br /> t - 4 v htS-1 -6Z,7-n'1�w o <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name I <br /> Lu C G CS•_-t %i-4 P 7-A4- G-.L. S2-i l3' '5cl41 <br /> Legal Description(as indicated on tax statement) q 0 <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit .`.- <br /> w � <br /> Addition Privy Moving Subdivision o 0 <br /> v <br /> z i S <br /> Structure Use: d -.r cxl\"nc <br /> (family home cabin, garage,addition,et4) <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). 1`I <br /> 2. Show the location of the well(W) septic tank(ST),and drainfield(DF). l`I <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. 11 / <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 lake, Q V' <br /> 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 0 0 <br /> the owner. <br /> PLOT PLAN ,�/I z <br /> C �vl o 0 <br /> 3I <br /> cn <br /> (1J i <br /> O <br /> r) ('0 <br /> S <br /> o /� � <br /> s <br /> (i <br /> z <br /> n <br /> f <br /> m caw S+ o Dacam <br /> m <br /> P <br /> P Mcoi 9 <br /> N =2i m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <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- ; y_r N i G <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 county officials charged with administering county ordinances or other authorized person to have <br /> access to the above des bed premises at any reasonable time for the purpose of inspection. 0~0 <br /> n w m <br /> �}('�� 1 � . i '• v N x E <br /> SIGN HER <br /> (sig a of owns o uilding contractor) (date) c <br /> $ <br /> ZONING ADMINISTRATOR <br /> I? o w� <br /> TOWNSHIP PERMITS MAY BE REQUIRED QN. <br />