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Bumbtt County 7410 Co. Rd. K, No. 102, Siren, WI 54072 Office of Zoning Administrator ; - 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. w m <br /> _ a1,t Z1 ►-nMQY" a o <br /> OWNER (Please P�U Contractor or Surveyor or Agent v <br /> 11 ( <br /> AddressZ.0 r � I� rr rq�3 Address <br /> I <br /> City,UUS9�Ltatlle7j�p,Cgde �aO� J City, State,Zip CodePIN <br /> Telephone Telephone <br /> -71-7-S C—:(j, red L <br /> Emergency/Fire No. and Fload Name AAA <br /> Legal Description (as Indicated on tax statement) <br /> c> e� <br /> Permit(s) Applied for: o It. t <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit o °- <br /> v <br /> Z o g <br /> Accessory Building Sanitary Privy Subdivision ° � <br /> Garage <br /> Structure Use: _ -Z <br /> amity hom /cabin, garage, addition, etc.) �C>l <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). o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfieid (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 zv <br /> measurement to the ordinary high water mark of lake,stream,or river. o S <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the pians must be signed and m y <br /> dated by the owner. --- �\ <br /> C I <br /> PLOT PLAN <br /> AJC � <br /> o <br /> m <br /> la <br /> I <br /> o c a a m <br /> M <br /> 9 < m m O 0 10 ; <br /> o f 0 XI <br /> _ -. 2 m <br /> �n O <br /> g mA � <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o C I m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <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 8 m 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. f <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m . <br /> _ A gA <br /> SIGN HERE ._ a <br /> (signature of owner or buitding�o ra to _- - (date) I x <br /> ZONING ADMINISTRATOR6 1977 <br /> TOWNSHIP PEF)IU�/ITS MAY BE REQUIRED N o o f5 m <br /> 88 8888m <br />