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C)') Q/ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � 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 n <br /> regulations- lo'f the State c Wisconsin, <br /> e HKJI.��9 uY/NJ c m <br /> n O <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> 3608 /9 "f 4ue So <br /> Addr ss Address <br /> City,State, ip Code City, State, Zip Code <br /> (0/a / 79a- 5b5 <br /> Telephon Telephone <br /> ,25043 <br /> Emergency/Fire No.and Road Name <br /> O�cs /7 /8 -7 !/�L}/ Q 156kW SU3 <br /> Legal Description (as Indicated on tax statement) o <br /> m <br /> Permit(s)Applied for: `= o <br /> o < <br /> Dwelling Addition ^ Filling/Grading Camping Unit o ° <br /> v <br /> Accessory Building Sanitary Privy Subdivision ° o° <br /> Garage <br /> Structure Use: cSy�P � S <br /> (family home/cabin, garage, addition, etc.) o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 � <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). Q o <br /> 3. Show the location of any lake or flowage- If within 1000 ft. and the location of any river or stream- if within 3 <br /> 7I a n <br /> 300 ft. 11 Z `v <br /> o n <br /> 4. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building n 5 <br /> to lake, river or stream, if applicable. m t <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. in <br /> M <br /> PLOT PLAN <br /> AQ 07. <br /> W EGC <br /> Fr(V07 /NCCUDidf odF i/9��c�� c <br /> o <br /> s <br /> m <br /> o <br /> N <br /> C� z <br /> I a <br /> f <br /> o c m ro o a 9 <br /> Dn� $ a <br /> o e < . Z H o a m _9 <br /> '�(� //;� .Nzii <br /> G1 � O <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ; ! m, : n <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- �' pp!! m <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- tg m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a permit. 1 <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 ro <br /> access to the above described premises at any reasonable it for the purpose of Inspection. m u, <br /> -m"tg <br /> ' ' 3 A <br /> € � 5 <br /> SIGN HERE '(signature of owns r ilding contractor) (date)ZONING ADMINISTRATOR ,TO IP PERMITS MAY BE REOUIRED I I� n" " o n"`� `"u to rn m888888 a) <br />