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Burnett County 7410 Co. Rd. K, No. 102, Siren, W154872 Office of Zoning Administrator w m o c <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> m c S <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 _ <br /> regulations of the State of Wisconsin. <br /> m v <br /> C <br /> n O <br /> O ER Please Pri ) / Contractor or Surveyor or Agent <br /> Rt <br /> �� �. f Lu lel {ti C S�l I p h Address Rt <br /> � 67d9 c�# <br /> City, State,Zip Code City,State, Zip Code r— r <br /> i AJ lA + <br /> Telephone Telephone <br /> � e '77� <br /> Emergency/Fire No. and oad Name <br /> Legal Descrlptlon (aef Indicated on tax statement) O o <br /> Permit(s)Applied for: o 0 <br /> 0 » <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z <br /> Accesso ilding Sanitary Privy Subdivision <br /> 1 <br /> arage <br /> L <br /> Structure Use: <br /> (family home/cabin,garage, addition, etc.) <br /> DIRECT"M1t£OR PL DtMkY1MNG: (Aei 8FV.top view) —� 0 <br /> 31 <br /> I qhnw buildings (FB) and all now buildings(NB) and Indicate orth ( ). 0 <br /> 2. Show the location of he well (W),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show dimensions infe of the following:(a) building toall lot lines,(b)building tocemerline ofroad, c but ding 1Aa c <br /> measurement to the o Binary high water mark of lake,stream,or river. o n <br /> 4. If separate plans ares bmitted by an architect,engineer,build n ra or,etc.,the Ian must be I ne and n n• <br /> dated by the owner. f m L 0 {}� <br /> C I 11 \ <br /> PL T PLAN N <br /> Z r-L <br /> wN <br /> O <br /> o <br /> I y <br /> _i ✓ Z <br /> li <br /> GCL'V m� n m <br /> nit a � <br /> o <br /> n <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of y knowl- o m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- w m w O <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 ag 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ut <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 80 <br /> A e <br /> SIGN HERE -i'lit s. / -Cn T.vA,� /O <br /> (sigi r of owne r uilding contractor) (date) k ' <br /> o : s <br /> ZONING ADMINISTRATOR <br /> SHIP PERMITS MAY BE REQUIRED o o�8 m <br /> 88888888 vi <br />