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Bufnett.County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> ns of the State of Wisconsin. <br /> regulRo AYiey S <br /> �- towt-LL f <br /> OWN Please P int Contractor or Surveyor or Agent m m <br /> (�C.14m <br /> Address, Address <br /> City,State,Zi Code City,State,Zip Code <br /> GPS— �11.f- '7 <br /> Telephone Telephone (� <br /> Legal Description (as Indicated on tax statement) <br /> 0 <br /> 0 <br /> Permit(s)Applied for: H <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> eG Ql z a lKr_ c <br /> (f miry homelcabin, garage, addition,etc.) <br /> DIRECTIONS FOR PLOT RAWING: (Aerial or top view) <br /> 1. Show the location and size of all existing buildings (EIB) and all new buildings (NB) and Indicate North (N). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfieid (DF). 3 <br /> 3. Show dimensions Infest of the following:(a)building to all lot lines,(b)buildingto center line of road,(c)building Z v <br /> measurement to the ordinary high water mark of lake,stream,or river. ° o I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. fA Jl ° <br /> C <br /> PLOT PLAN M <br /> Ly� <br /> Z)eclrl- a ' (� � o �Pe 7L 75 0 <br /> SPTh4c dL ��p��r /r m eK tCn <br /> o I� <br /> o <br /> z <br /> /O 4* <br /> C l/' �U ( �1�r 7° o c � m m o a ro <br /> ��� A 00.(.n <br /> is <br /> M <br /> ec : m <br /> o <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- irn m O <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. 1 8 m $ <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- yt <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have . o <br /> access to the above d scribed premises at any reasonable time for the purpose of inspection. , _ 3 g R <br /> a <br /> SIGN HERE <br /> a : <br /> (si nature of owner or 1 n c t ( e) o ? <br /> � l� giii <br /> ZONING ADMINISTRATOR <br /> ks <br /> TOWNSHI PERMITS MAY BE REQUIRED R .8� rry <br /> !8888u <br />