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C p\ ( C�r 7)iN' <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> 2 o <br /> y <br /> TO THE ZONING RdMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown mrein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett <br /> urnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. — �-- <br /> N � <br /> 9m 7WUrnAs ` <br /> a o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> ^J �d al W I ) i 7' N < 7 all <br /> Address Address 1 <br /> T3 l &Vrn t r' ro,A..7 mAJ. £SLf38 <br /> City, State,Zip Code City,State,Zip Code (� <br /> (n1 � 9yI 7J <0 pC ' <br /> Telephone Telephone <br /> y'7 ^JO Te <br /> ririj:� 2 n <br /> EmergencylFire No. and Road Name 3 <br /> Legal Description(as indicated on tax statement) <br /> n 0 <br /> Permit(s)Applied for: 0 -C <br /> New Building Sanitary FillinglGrading Camping Unit <br /> m <br /> Addition Privy Moving Subdivision o <br /> - Z a <br /> Structure Use: ° <br /> (family homeicabin, garage,type of addition,etc.) `D <br /> z <br /> Directions for plot plan drawing: <br /> 1.Show the location and size of all existing buildings(ES)and all new buildings(NB)and indicate North (N). <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield(DF). o <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- <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 O <br /> the owner. o <br /> - �eboltC 3 <br /> PLOT PLAN ON !/Y ,Q� I - ^ <br /> OUefitly 1,S q0TO <br /> m <br /> Z <br /> o n <br /> ar 1' o <br /> I <br /> � e <br /> f� <br /> T _ <br /> a <br /> ►'1 , — ? <br /> B --\C:�'�4T o OFV <br /> fi Z <br /> d N• 9 <br /> A03 e v <br /> D ! K <br /> 6� <br /> m c=md 0ncc m <br /> 0 0 ` m '2 ' <br /> m <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- \Q 9 <br /> J A <br /> edge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all informs- oo: C <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 1N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 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. m <br /> m <br /> g,- <br /> SIGN HERE ` `^ <br /> (si re of owns building contractor) (date) o `a <br /> ZONING ADMINISTRATOR d o [ o <br /> M T <br /> NON Nm <br /> TOWNSHIP PERMITS MAY BE REQUIRED /( ��0+000 o m <br /> �,Jo 0 0 0 o fA <br />