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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m o c <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> m o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v m <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 a.w ins ia..o and 3 <br /> regulations of the State of Wisconsin. H o <br /> n E <br /> OWNER lease Prim Contractor or Surveyor or Agent m { <br /> )CN ut_ My£ Y FLa1ar►.t GONSTPULT L�/Y <br /> Address, Addres <br /> -391q ILi o� � s?- U, <br /> City, State, Ip Code City, St� Zip Code <br /> Lu � , wi 5'� g9� � )2Grv , wt X443?z- <br /> Telephone Telephone <br /> 11S- Xi�G�AS � l5 4R - S06Z <br /> Emergen�ty/Fire No. and Road Name <br /> �YIAwLia�U 1wL�Q_ gOL l�d --rM tD 1-4Jf <br /> Legal Description (as Indicated on tax statement) <br /> 3CAt, <br /> Tg/1�091T4 Permit(s)Applied for. <br /> T(fiL o <br /> ,5-ACAs Tt <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit 0 o <br /> v <br /> z o <br /> Accessory Building _ Sanitary Privy Subdivision o } <br /> Garage <br /> Structure Use: 6:� <br /> 0 <br /> (family home/cabin,garage, addition,etc.) <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). <br /> 2. Show the location of the well (Vi),septic tank(ST),and dralnfieid (DF). 3 u, <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building Z o <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 O m <br /> dated by the owner. C 1 <br /> PLOT PLAN N M (� <br /> m <br /> r�� 8 <br /> co rralTP <br /> i �.J6' —moi � _ � <br /> m <br /> o <br /> r <br /> 08 z <br /> I� <br /> al <br /> _.. <br /> A ° > > y m <br /> [ m <br /> rii [ OO <br /> u co C <br /> g ' m m : 21 <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my 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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- )$ m y' <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I 8 a 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 �„ <br /> access to the above described is at any reasonable time for the purpose of inspection. ' m Q <br /> m ; a <br /> m : <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR v I.m ��1�°� - g <br /> N_ <br /> TOWNSHIP PERMITS MAY BE REQUIRED &' N a o m <br /> 9899;88rmo <br />