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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator V m o a <br /> APPLICATION FOR — LAND USE — PERMITS3_ <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. m <br /> (� o c <br /> �S t.t.l. E <br /> OWNER (Please Print) Cont r or S <br /> _ rveyor or Agent o <br /> Address <br /> ,s71'CA/Y oAdd 1 856 a� orA �c m � <br /> ss <br /> lona 0-HCR f nAuir ul. S(1930 <br /> City, State, Zip CodeCity, State, Zi C de <br /> ,PPoyAXe)? J"yd'o / cGfn 7ya <br /> Telephone Telephone <br /> ii8y�o i <br /> Emergency/Fire No. and Road Name n <br /> 1 <br /> Legal Description (as Indicated on tax statement) _- p�' '3 (I�jn r/� / P� P3/ <br /> � o <br /> Permit(s) Applied for: 0 ;- <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z oL in <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage `I <br /> Structure Use: 1400< 0h a '• n(�fi— A7 ioti 1100K CJA4 IQ 1,6X a <br /> (family home/cab n, garage, a dition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: X <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). v m <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if withinon <br /> 300 ft. o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m <br /> to lake, river or stream, if applicable. fA 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C I <br /> dated by the owner. 1A _ <br /> P(_OT LA <br /> — 1 <br /> , W <br /> JhC O <br /> I D m <br /> q'- I h� <br /> ? �� 01� IGprSe )�yd�x .�ge flu' s !ay 3,z ) Z <br /> ---------- - D <br /> Ids i I <br /> li n f <br /> I <br /> i <br /> o rn v ur r D D p m <br /> 1 <br /> .o P [ m: a <br /> _ <br /> 1 ^r – m <br /> $ : n , <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 m 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- yy!!m 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 8 m <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this A N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have O <br /> access to the above described premises at any reasonable time for the purpose of inspection. . m $ <br /> m 3 A u <br /> rJ m m <br /> SIGN HERE � <br /> (si at r <br /> ZONING ADMINISTRATOR of owner r tiding contractor) (date) o x <br /> • q <br /> TOWNSHIP PER ITS MAY BE REQUIRED ON N N N 8 8 O m <br /> t 88888888m <br />