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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 a o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO YHE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � N <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the A `m <br /> Burnett County Land Use Ordinance Sannab n Cod an with all other applicable County Ordinances and the laws and 3 0- <br /> regtigns of the Statepf,N{Iscons' 4Z 46 c d <br /> c}v�� p f <br /> f <br /> OF Pleats Print) Contractor or rve r m <br /> Addr?o v Address <br /> City, �l &I D Cry,State,Zip Code <br /> My& <br /> Tele hone Telephon <br /> CeZ 2___ <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax Statement) <br /> s�GCS �, ��3 p �s� a o 50 <br /> Permit(s)Applied for: 4 �� 3 i r 3 <br /> r (V <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit S 75 <br /> Z o <br /> Accessory Building lSanitary Privy Subdivision ° <br /> Garage �'/ !//V <br /> Structure Use: 0 <br /> 0 <br /> (family home/cabin,garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 2 <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 drainfield (DF). G v w <br /> 3. Show dimensions In feet of thefollowing:(a) bulldingto all lot lines,(b)building to center line of road,(c)buildingZ c <br /> measurement to the ordinary high water mark of lake,stream,or river. o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m n' <br /> dated by the owner. C <br /> PLOT PLAN <br /> 1 <br /> 0 <br /> I� <br /> I U� N <br /> h o <br /> � o <br /> 22 >< <br /> 10� <br /> o <br /> Z <br /> o� � d � � <br /> om <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o m c : 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- wt!, m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- Oro ro <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ m $ <br /> further accept all liabili which may be a result of County of Burnett relying on this information I am providing in this ap- y, <br /> plication. I agree to Krot county off' 'als cha with ministering county ordinances or other authorized person to have 91m 0 <br /> access to the ab scribed p s y aso lime for the purpose of inspection. $ <br /> m V A w r <br /> I <br /> SIGN HERE N c <br /> in .2 <br /> [ding (datei <br /> (signature o uicontractor) <br /> ZONING ADMINISTRATOR O <br /> g <br /> N <br /> TOWNSHIP PERMITS MAY BE REQUIRED N IN,8 <br /> �) OCT _ 91992 8888888 <br />