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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ( a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> u o <br /> TO THE ZONIrjG 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 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of he State of Wisconsin. II m o <br /> ��Vr�t'� <br /> 1D o <br /> OWNER(c 00 ease Print y�_ , Contractor or Surveyor or Agent <br /> 7y\ m <br /> m <br /> Addre�l � � 1' �C Address <br /> City,StZ'p CodeCity, State,Zip Code <br /> ? ( <br /> Z2 - �SIZ <br /> Telephone Telephone . QQ <br /> � d j <br /> Emergency/Fire No.and Road Name rte' <br /> M <br /> Legal Description(as indicated on tax statement) o <br /> Permit(s)Applied f G) <br /> 0 <br /> New Building Sanitary Filling/Grading Camping Unit <br /> Addition Privy Moving Subdivision o <br /> o C7 <br /> Cab;Structure use: Z co <br /> (family home/cabin, garage, type of addition, etc.) � 4- <br /> UJ J <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- (/1 1 <br /> nary high water mark of lake, river or stream, if applicable. f� <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 v ti <br /> /n 0 <br /> �.J <br /> r 01 <br /> o <br /> 0 <br /> o <br /> 0 <br /> N IIL� <br /> _ V <br /> 4`` Z <br /> [govd,,// '' L <br /> J f!')�2'Y L ]7 mv(nr DDW -0 <br /> N.�e3{'Ybm c m m o a <br /> fKtd f��rpt tW m n ..:a y a S <br /> U), �4> Z d 3 <br /> gol�'Ice w - �s a _ zHo �m <br /> LN: i <br /> 45 <br /> I declare that this application(including any accompanying schedule)ha�xamined by me and to the best of my knowl- p o i Ems; y <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- p <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. <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 /> o »; <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> T \n: <br /> N : i <br /> SIGN HERE '� � / `�' ! �mE d, <br /> (si na e f r buil ' r) (date) [ 03 g <br /> 1 b <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDo o o o tmn <br /> noo 00 <br />