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l <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> TO THE ZONING 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 m O <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> Exn / N m <br /> -ve7 W E, uR,,,,L Sk 5-C a o <br /> CI NER Please Print) Contractor or Surveyor or Agent o <br /> 323 ti, ash .,RwL ck �� m <br /> Address Address <br /> S A ,off �a 6c.r ,/ i S`/ F 7 / /v`\ <br /> City, State,Zip Code City,State, Zip Code <br /> Telephone Telephone 17)W <br /> Emergency/Fire No. and Road Name <br /> Jl <br /> Legal Description (as indicated on tax statement) R <br /> Permit(s)Applied for: `y/,1 0 0 -� <br /> Dwelling 4- Addition Filling/Grading Camping Unit o <br /> v <br /> Z 0 <br /> Accessory Building Sanitary _ Privy Subdivision ° ro <br /> Garage <br /> Structure Use: <br /> - (family home/cabin, garag ,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 0 z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and A y <br /> dated by the owner. M <br /> DQ <br /> C 1 <br /> PLOT PLAN <br /> l_ m <br /> o <br /> N <br /> 3 C d 0 <br /> X a <br /> �,rluv' <br /> oc M. m mnaFT <br /> a a� a� <br /> N 1O <br /> 21 M <br /> o <br /> 8 <br /> a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m 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. I I�Oio <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 u <br /> access to the above described premises at any reasonable time for the purpose of inspection. ,t 3 <br /> ro <br /> ro <br /> SIGN HERE Z 9 <br /> �: d <br /> (signature of ow er bu� Ig c n r) (date) c s <br /> ZONING ADMINISTRATOR <br /> TO SHIP PERMITS MAY BE REQUIRED U"55 5 0 0 6 a <br /> --888 8R <br />