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?✓L <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o oz <br /> APPLICATION FOR — LAND USE — PERMITS 3. ' <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v 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 0_ <br /> regulations of the State of Wisconsin. w m <br /> e J),' 4 Al �A �91� ,f <br /> OWN R(Please Print) Contractor or Surveyor or Agent c <br /> /7 .s= /3C'SC 515 <br /> Addres Address <br /> City, Stato Zip Code City,State,Zip Code <br /> Telephone Telephone — <br /> 7%5 — <br /> Emergency/Fire No. and Road Nam-ey�., <br /> mph <br /> c� 7G_( f117 'QL <br /> Legal Description (as Indicated on tax statement <br /> 3 ct <br /> Permit(s) Applied for: o <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage ) v ^yg ' D <br /> Structure Use: 5C,p££ A) �nus� Id o <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). 0 <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 3 <br /> 3. Show dimensions infeetofthefollowing:(a) building to all lot lines,(b)buildingto center line of road,(c)building M z `c <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and mm <br /> dated by the owner. <br /> c � <br /> PLOT PLAN m <br /> aaw-&J, <br /> S. -ee lwale�41 <br /> N <br /> n <br /> p <br /> ,o `p <br /> G� &rm 4, y <br /> 0 o c m m n m <br /> a < < •Z goo 8 m 3 <br /> P @ o m .Z <br /> t O _ N : M <br /> _ » . m <br /> U ii = O <br /> 'mom € c <br /> 8 i <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- S 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 O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 0 u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.1 agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described premises at any reasonable time for the purpose of inspection. mg 0 <br /> aA <br /> SIGN HERE 3 <br /> (sure of o building contractor) (date) o s <br /> ZONING ADMINISTRATO g <br /> TOWNSHIP RMITS MAY BE REQUIRED ON o 8 m <br /> 8m <br /> 99998 80 <br />