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.ounty 7410 Co. Rd. K, #102, Siren, WI 54872 Office of Zoning Administrator w v --I z <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> id as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> .County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> ,ins of the State of Wisconsin. <br /> �ERdr�?fSr3 7 7�LnNS e <br /> PI a l E <br /> ( ) Contractor or Surveyor or Agent � <br /> Address Address <br /> ST �v L �i/•UN hs/Ol t <br /> City,State a City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit G) <br /> 0 <br /> Privy ( ( Subdivision m <br /> r x <br /> Structure Use: o G 9.�'fl(rG' `��t` �/ — c ,TCJt`a�5 SZ - v <br /> (family home/cabin, garage,addit' n,etc.) o o Q <br /> a <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. o <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. 6. Provide legaln land description. 0 <br /> �' "N' <br /> PLOT PLAN W R OO�ey �.-r1-t� 3 <br /> P N <br /> �q1 o n <br /> 5. <br /> N <br /> a cX-N <br /> i <br /> s :r <br /> W ` <br /> -0 <br /> o <br /> n <br /> Z00 <br /> Z <br /> Z <br /> t 9 <br /> (J D fn V(nr D Dm-0 <br /> 0c -.m 00ac m <br /> m ci, -=am anz <br /> H Zmp �to � <br /> Z'I m <br /> u ; 1 p <br /> C, <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my S <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that A <br /> PP li 9 Y ) t ? O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <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 aree to permit county offic' Is charged with administering county ordinances or other authorized n <br /> person to have acce o the above described mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (s� na a of owneyer wilding contractor) (date) ,��, <br /> o: o <br /> ZONING ADMINISTRATOR �� ✓ ` o ` o <br /> T <br /> N NON m <br /> TOWNSHIP PE ITS MAY BE REQUIRED NN��o, N <br /> �00000 0 <br />