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M � <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord 0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein.Ti+e 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- 3 n <br /> tions of the State of WISCO <br /> 42 - l4 l � I ///� a C" o <br /> OWR(Please Print) Contractor or Surveyor or Agent F <br /> Address / Address ` <br /> City,ttate,Zip Cod City,State,Zip Code <br /> Telephone / / Telephone I <br /> 2L /�G{/fes -mss! 'r Ar- <br /> Emergency/Fire No. and Road Name "b <br /> Legal Description (as indicatedtax statement) <br /> Permit(s)Applied for: ° O <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit m <br /> r <br /> Addition Privy Moving Subdivisiono o <br /> — 1 v -- <br /> Structure Use: ��Jl�✓ o o F <br /> (family home/cabin, garage, type of addition, etc.) <br /> rTy <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). <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 PLAN z (T1 <br /> o D n <br /> '140/'yz _ <br /> �t 1 k <br /> O <br /> x to <br /> _ o <br /> a = <br /> o w <br /> v, <br /> w � o <br /> 10 <br /> 2 <br /> a <br /> CSS � <br /> A NVCf)r DDmrn <br /> m <br /> Z O <br /> 0 , <br /> b: <br /> [ o: <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl-� p 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- o m <br /> tion contained in this application(including an accompanyingschedule and I further declare that I recognize that this infor- o <br /> PP ( 9 Y ) 9 � <br /> On <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 /> 00 <br /> Om <br /> SIGN HERE d+ <br /> (sig at a of own b ilding contractor) (date) o b" <br /> ZONING ADMINISTRATOR <br /> �J O NT <br /> T V• OONm <br /> TOWNSHIP PERMITS MAY BE REQUIRED po 0 0 0 o m <br /> 00 000 V1 <br />