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Burnett County 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� H <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett 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.� p <br /> 1�n � /E�Qg�l1�'� 0 =' O <br /> OWNER(Pie a Print) T Contract r or Surveyor or Agent <br /> ��-Fe Adam , /I�,(-! "- <br /> Address r r—fJ p h ddress ( <br /> S 1 ] 7i7 Z�7-5 ! . W <br /> City,State,Zip Code City,State,Zip Code I <br /> Telephone Telephone <br /> Permit(s)Applied for: N <br /> New Building / Filling/Grading <br /> Addition ✓ Moving o <br /> Sanitary Camping Unit O <br /> 0 <br /> Privy Subdivision 0 ,`c- ^ <br /> N <br /> 0 <br /> Structure Use: -i/t�n� I O(e?'-) <br /> (family home/cabin, garage,addition,etc.) o v° <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- 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 lake, <br /> river or stream, if applicable. <br /> 5. If,separate plans are ubmifted b an ar hiI0 <br /> ect, n ineer,ltuildgr,contractor,etc.,the plans must be signed and dated by e <br /> the owner. 6. f�rovide �lega� an description. e J <br /> 0 <br /> PLOT PLAN c N <br /> Z <br /> _ . _ . <br /> o <br /> 0 <br /> h <br /> T�x <br /> � z <br /> 700 N <br /> o n <br /> � V <br /> _O <br /> h— <br /> z <br /> .DfiUe `L° r z <br /> I <br /> T-3 Yd `� rYIAA! 5 2 42- <br /> m c�m ori aim <br /> m <br /> m n < o <br /> RcA z c <br /> z o' 1 <br /> € z <br /> M <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a tt oo <br /> J� <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing w <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the ab�ve described PA emises at any reasonable time for the purpose of inspection. <br /> N <br /> SIGN HERE <br /> (si ature wn r or contractor) (date) <br /> ZONING ADMINISTRATOR <br /> OWNSHIP PERMITS MAY BE REQUIRED o u <br /> � <br /> uuvv o mm <br /> 0000 0 <br /> 0000�tA <br />