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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator M f o <br /> APPLICATION FOR — LAND USE — PERMITS - 3. ' <br /> d Q <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m c <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 3 n <br /> regulations of the State of Wisconsin. w m <br /> 11i (OREt. DADA SELF a <br /> OW2PIease Prin Contractor or Surveyor or Agent o <br /> �' Merrf' iZ0 - RT 3 <br /> I�IJ�I� tAt �S . W^ - 5`4012 <br /> Address <br /> / <br /> City, State, Zip Code City, State,Zip Code ) <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n 0 <br /> Permit(s)Applied for: 6 �. <br /> Dwelling Addition Filling/Grading Camping Unit E <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage pAil ! <br /> Structure Use: ' 6- " /� <br /> (family home/cabin, gar e, addition, Ird <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> 1 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate Nort ). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). o v, <br /> 3. Show dimensions infest ofthefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building z `v <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. C �j <br /> I <br /> PLOT PLAN m <br /> N <br /> -C <br /> N <br /> o <br /> 1 <br /> Z <br /> ) <br /> p o c w a n a 0 M <br /> m. Da� m p N <br /> 2 m N M <br /> p fesc : '! m <br /> C <br /> $ n � C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my,knowl- m m 9 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- 4 w m N ma <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 g N 8 <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, o <br /> access to the above described premises at any reasonable time for the purpose of inspection. N $ m <br /> r 3 n <br /> SIGN HERE <br /> (signs ure of own o ui d'rco <br /> ZONING ADMINISTRATOR L r I $ <br /> MHMMT <br /> TOWN HIP PERMITS MAY BE REQUIRED I f1 2 o 0 8 m <br /> \1 88088 $ $ y <br /> 1,1I�C Se/) qi-c 7TH U --- <br />