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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m c o <br /> _-. <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H <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 <br /> regulations of the State of Wisconsin. w m <br /> w � <br /> NAD !SCOTt- MKS15IRLD <CS $ <br /> OWNER (Please Prim) Comra or Surveyor or Agent o <br /> Address Address <br /> 5t'j- paUL I�1fJ, 550?� ` - <br /> C ty,State,Zip Code City, State,Zip Code G <br /> 4oIZ — 45-6 -193 <br /> Telephone Telephone <br /> Ll,}ZS L.IL.LKy LI10L <br /> Emergenc�L/Fire No. and Road Nam -->> <br /> [TuL wtc &IJbiaG LOT 1? <br /> Legal Description (as Indicated on tax statement) o <br /> c> i <br /> ermit s 0 <br /> Applied for: o <br /> yj <br /> Dwelling Addition QFilling/Grading Camping Unit � <br /> v <br /> Z o <br /> Accessory Building Sanitary PrivySubdivision o <br /> Garage <br /> Structure Use: <br /> (family me/cabin,garage,addition, etc.) U`- <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). C l <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (DF). 3 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building Z Q <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 m <br /> dated by the owner. m 0 <br /> PLOT PLAN <br /> II � N <br /> 0 <br /> Iz N <br /> V O <br /> C16 <br /> N B 2 <br /> o Y Zor ($ X Z ul <br /> o » <br /> I <br /> V Ib0 Z <br /> d -7w, <br /> r � <br /> �Do <br /> o c m mr tni Q E 19T1 <br /> �. 00. 0a = M <br /> v < 5 ' Z w o 30 ro <br /> % 3 <br /> Z o ! i <br /> n m <br /> a C C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- In <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> motion I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. <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.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. m 3 g <br /> m ^ m <br /> 'C �'ccsvo2d, / m <br /> SIGN HERE � ���,� <br /> ' m <br /> (signature of own o uil co t f) (date) hL ; <br /> ZONING ADMINISTRATOR g . <br /> « <br /> TOWNS IP PERMITS MAY BE REQUIRED <br /> 88888888rmn <br />