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O�tZ Ca dV l <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 9 £ <br /> TO THE ZONING-ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y (— <br /> located as `sown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a �l} <br /> tions of the State of Wisconsin. o l <br /> 06cNZ_�1 <br /> OWNER Please Print n O <br /> �Q�Q o) ^ �� ` Contractor or Surveyor or Agent w <br /> 1 1 1 11 /l , r n 0 <br /> 1 ,1 �l r'�VV'JJ^�� m 1 V <br /> Add V-i W "V 1 �-tC+ J A dr955 �� t-- �5 / , ( <br /> City,State,Zip Code City, State,Zip C06 I )l�� <br /> --� I!S' - [ - 3315 <br /> Telephone Telephone <br /> 3\q Ii U., Ck <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for. <br /> o <br /> New Building Sanitary Filling/Grading Camping Unit <br /> N <br /> Addition Privy Moving Subdivision o 0 <br /> 4" a� (:W X / <br /> Structure Use: a 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. ^°r <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 /> 0 <br /> PLOT PLAN 3 <br /> Z c <br /> o Q <br /> 0 <br /> o' <br /> _ <br /> t <br /> IA 0 <br /> N <br /> �� 1 <br /> a o <br /> a = <br /> N <br /> 0 <br /> n� <br /> V <br /> Z <br /> N c 0 m 0 a Cm m <br /> n Q< J = On-. m <br /> Z o N Q <br /> O = : <br /> Z. <br /> C m <br /> u„ � O <br /> o C <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- V� a <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 l/ 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 /> T : <br /> SIGN HEREQ� <br /> l (si re of owner o building contractor) (date) o o <br /> ZONING ADMINISTRATOR ' <br /> o: o <br /> J N O V <br /> TOWNSHIP PERMITS AY BE REQUIRED <br /> t 00000 <br />