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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d - 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> ;v o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 1? 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 <br /> 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 v <br /> .tom rl , sP� �,u 5�l �, <br /> OWNER Please P ' I) Contractor or Surveyor or Agent n n £ <br /> 1 � S <br /> Addres Address <br /> City,State,Zip derCity, State,Zip Code <br /> z s�-r- i3s }, I <br /> Telephon Telephone <br /> V <br /> DJ <br /> Emergen /Fire Noafrd Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: n o <br /> New Building Sanitary Filling/Grading Camping Unit 0 .`.- <br /> '° r <br /> Addition Privy Moving Subdivision g g <br /> e _ Q o <br /> Structure Use: ya <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. <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 <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 o <br /> the owner. <br /> 1Iv rn <br /> PLOT PLAN o n <br /> cam/ = <br /> Mr o <br /> J <br /> M -C <br /> a <br /> u, <br /> �a. I. g <br /> 0 <br /> o <br /> 20 r 3 <br /> d � <br /> Z <br /> i 17 Wv[n�DDOoy <br /> m a� '-nm aaa <br /> • (�/j.�// Ei N <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- i ? A <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible forthe detail and accuracy of all informs- - i m <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 <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- f gag <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized pe rs n to have <br /> access to the above descr' ed premises at any reasonabl t me for the purpose of inspection. E n^o; <br /> q n : <br /> �� l o � - a nu+i•'c <br /> SIGN HERE Hm N' <br /> (sig to o ner or b ' co ractor) (def ) o g <br /> ZONING ADMINISTRATOR E ' '• <br /> H��fA' T <br /> TOWNSHIP PERMITS MAY BE REQUIRED PSN" m <br /> oa o N <br />