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7410 Co. Rd. K, #102 r,i-) <br /> Siren, MI 54872 <br /> Burnett County Office of Zoning Administrator m o a <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> N o f <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <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. �Ur�yPD .�/ a+r1+-LU <br /> nnroovRrrr F Leet,,qLy 10 o <br /> OWNER(Please Print) Contractor or Surveyor o Agent <br /> ent o <br /> :3/030 r,FAX tVe . A . !.? o , Rdx i 3I <br /> Address Address 1 <br /> �' d: Igim . S5 W/ �1 <br /> 2 /) ek eu r M/J/• �SSo_37 <br /> City, tate,Zip Code City, State,Zip Code <br /> /n/� 6Zgz1 1 <br /> Te phone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n c1 <br /> 0 <br /> Privy X Subdivision 0 <br /> r <br /> Structure Use: I h, <br /> o ° <br /> (family homelcabin, garage, addition,etc.) o 0 <br /> m <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- it within 300 ft. 0 <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, <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 by <br /> the owner. <br /> 1��p 1� O <br /> AL ( PLAN a ega description as on ax statement) on the side of this form. 0 <br /> E a m <br /> /1/O �l-e SS' u vl z.p <br /> 0 0 <br /> C5/ r <br /> �i <br /> do 0 <br /> Sri <br /> 0 <br /> N <br /> o <br /> 17) <br /> `C k r^P�iN L -1 <br /> go= I(VX-Lo �s t +— �stdy <br /> tN <br /> KI 2- 046 +�Go'� L1 <br /> 0 <br /> r� L Z Z <br /> I <br /> e. I <br /> � 0D� <br /> N `G 'O.M - a <br /> O G <br /> co O J <br /> u w O J <br /> m <br /> � c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my - 0 o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all i m <br /> PP (including Yaccompanying ) g �� )) <br /> information contained in this application includin an schedule and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n i <br /> person to have access to the above described prem' es at any reasonable time for the purpose of inspection. <br /> T <br /> m <br /> SIGN HER <br /> (signal a of owner or b in cc tractor) I (date) <br /> ZONING ADMINISTRATOR <br /> OWNSHIP PERMITS MAY Bi REQUIRED moo. o, <br /> 0 00 0 <br />