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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d' `�" '� <br /> APPLICATION FOR — LAND USE — PERMITS 3 £ '' <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work des crib <br /> edddd and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of te�Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and r gula- 3 n G <br /> tions of the State of Wisconsin. _ <br /> o <br /> �eJoMP doss C <br /> OWNER(Please Print) nn 1_ Contractor or Surveyor or Agent n O <br /> m m <br /> Address Address m <br /> HIFaS1 try ��s WK/ 55033 !� <br /> City, State,Zip Cod City,State, Zip Code N <br /> 17 - 93`7- 1790 01Tele hone <br /> 73 G �l Telephone h, <br /> O ni.wTy10 <br /> Emergency/Fire No.and Road Name <br /> W Yz F S `h 0 F Q YL NW / i of rye`/,I oecjibf '►�1 yg 17 <br /> Legal Description (as indicated on tax statement) O <br /> Permit(s)Applied for: O <br /> New Building Sanitary Filling/Gradingo I, <br /> Camping Unit � (} <br /> Addition Priv <br /> Y Moving Subdivision o o v1 <br /> Structure Use: /log S.•✓ Z <br /> o <br /> (family home/cabin, garage, type of 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). <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. o <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 datl'd by <br /> the owner. n <br /> 0 <br /> PLOT PLAN 3 <br /> a <br /> Z c <br /> o n <br /> O <br /> a <br /> J__ z <br /> pF rn <br /> 1 r <br /> N <br /> O 5� a n <br /> 0 <br /> AQ <br /> x <br /> r s✓ 0 g <br /> t <br /> 560 �6 <br /> t <br /> I <br /> 2-s� <br /> M c;!mm o nwv <br /> m n� 2.nma y <br /> a <° °ici"oi3 ' 3 <br /> Z T. ? N O O <br /> oK. r.J R o z <br /> M <br /> E-"2 O <br /> =E• [ C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my kn wl. o; ;moo <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all info a- o' m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this i for- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I :tea <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- ` ? !ei» i <br /> plication. I agree to permit county officials charged wimth adi 'stering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable" a for the purpose of inspection. <br /> SIGN HERE <br /> (sign ur(/of owneK ilding contractor) ( :our <br /> o.0: n9 <br /> ZONING ADMIN/ RATOR l-" `-"— c m i ';n o <br /> n;n -n <br /> TOWNSHIP PERMITS MAY BE REQUIRED ( . 1 71994 '�'�'oNpJpm <br /> i <br /> ,u,V'vt vtooSPIn <br /> ' 'i��oo ooQYA <br />