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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; a c <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <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. H d <br /> c m <br /> Date Laheon a f <br /> OWNER (Please Print) Contractor or Surveyor or Agent o m <br /> 2135 DAapen Ave. <br /> Address Address <br /> St. Paul, MN 55113 r� <br /> City, State,Zip Code City, State,Zip Code l <br /> 1715) 635-2019 <br /> Telephone Telephone rib <br /> 3059 <br /> Emergency/Fire No. and Road Name <br /> Lot 1 CSM VoE 13 Pg 267 Section 19 T40N R14W. Town of, Scott <br /> Legal Description (as Indicated on tax statement) ' <br /> O .. <br /> Permit(s)Applied for: 0 <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary X Privy Subdivision ° } <br /> Garage <br /> Structure Use: San-rtaA OntV. t id I m <br /> (family home/cabin, garage,additi , etc.) Mill <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 3 N <br /> 3. Show dimensions infeet ofthefollowing:(a)buildingto all lot lines,(b)buildingto center line of road,(c)building Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. CI ° <br /> PLOT PLAN <br /> fn <br /> 0 <br /> N 90 <br /> vT �1J <br /> SEE ATTACHED \) <br /> z <br /> I <br /> m m v m m 0 a m <br /> mem an >] <br /> a m < C N o 3 <br /> Z �Sq. ci : 'Z � � ? mi <br /> o Y [ T to a <br /> Te Vic : p <br /> N m C C <br /> 8 ' € m m : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowI- 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 N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m ut <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 liability which may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. Iagree to permit county officials charged with administering county ordinances or other authorized person to have O P o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> m 3 A x <br /> Wade Ru �hoEm 5/13/92 <br /> SIGN HERE H i <br /> (signature of owner or building con r♦, �� _ ate) [ ` <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REOUIRED 0 U` SAN 8 8 8 m <br /> m <br /> , <br /> $8888888 u <br />