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On e C),01//) <br /> Burnett Couwty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c T o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> w O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m '!Z_nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. m m <br /> , U) tIl ) a.m � <br /> 0 <br /> OWNER(Please Print) — Contractor or Surveyor or Agent a <br /> J� trdQn ( I�JL <br /> AddresS, ^� SS(I . Address m <br /> City,Stae,Zip C9ode�Q a I n t \ \ City,State,Zip Code <br /> Telephone —1 Telephone Q <br /> Emergency/Fire No. and Road Namq'.�lp* :J4 <br /> fI I ukAO r.,/ <br /> Legal Description(as indicated on tim statement) Q <br /> Permit(s)Applied for: 0 o <br /> New Building Sanitary Filling/Grading Camping Unit w <br /> Addition Privy Moving Subdivision o a <br /> v <br /> Z 'o <br /> Structure Use: ° v <br /> (family home/cabin,garage,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). o <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. 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, 0 <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 byO a <br /> the owner. 0 0 u <br /> PLOT PLAN Z `c <br /> o a <br /> 011 <br /> w <br /> m " <br /> 0 <br /> o <br /> N <br /> (N <br /> n� N <br /> l.f n <br /> O <br /> ,lll�^y1llf <br /> O <br /> IY, <br /> J <br /> m <br /> 0 � <br /> W <br /> A <br /> Z <br /> l <br /> G <br /> D my Mr D D W-0 <br /> cam'> > onCm <br /> m n� -nm ';n9 <br /> 0 0 <br /> w: Qiooao _ <br /> g 'mc C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S: ; m'm <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- c>=E i ' m <br /> tion contained in this application(including any accompanying schedule)and 1 further declare that I recognize that this infor- 4 ? O <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I V ; <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. f n^o; <br /> m Ei 3 OX : <br /> s <br /> SIGN HERE ,r�T �'W.� � -- $'• <br /> (signature of owner or b ilding contractor) " (date) '• o <br /> ZONING ADMINISTRATOR <br /> S"'t N • <br /> ww�winwtn�l <br /> �^� <br /> OWNSHIP PERMITS MAY BE EQUIRED ��� m <br /> $$8SS$$tn <br />