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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm O o <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> m d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <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 <br /> regulations of the State of Wisconsin. H m <br /> 0 <br /> f <br /> OWNER (Please rim) Contractor or Surveyor or Agent o <br /> 7sos 1�Ecnro �.v, 7C <br /> Address Address <br /> 'r(r+ c)Q <br /> City, State,Zip Code City, State, Zip Code (� <br /> 613, - yss-k9Yo CU 1\j� <br /> Telephone Telephone <br /> ? 'R3-72- So.PECM-57FO F-D 9J , <br /> Emergency/Fire No. and Road Name ll <br /> Legal Description (as indicated on tax statement) o <br /> Qj <br /> Permit(s) Applied for: o °- (-1 <br /> Dwelling Addition Filling/Grading Camping Unit o °— V1 <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision ° �( <br /> Garage <br /> Structure Use: <br /> (fatuity home/cabin,garage, addition, etc.) r <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). n <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). 3 <br /> 3. Show dimensions infeet ofthefollowing:(a)buildingto all lot lines,(b)building to center line of road,(c)building � z c <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <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. C <br /> PLOT PLAN <br /> � N <br /> I n <br /> Ji <br /> O <br /> N I*�i <br /> > 7I _ <br /> O y <br /> N <br /> Z <br /> I z <br /> f <br /> A o c 7 y m D Da p Mm <br /> ry D 4 m d m d A a <br /> v < < <br /> 00 30 <br /> om o m ,Z M <br /> F > T N M <br /> 'w c , m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 0 <br /> 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 informa- u m w O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 a 8 <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- 111 <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have [srt N <br /> access to the above ascribed premis sat any reasonable time for the purpose of inspection. m Cj 3 8 o <br /> p m m A m <br /> SIGN HEREn <br /> ( gnaturs of owner or buil ing c t clo ida [ x <br /> ZONING ADMINISTRATOR f I f <br /> TOWNSHIP PER TS MAY BE REOUIRED l U _ N . o o m <br /> a <br /> 888 8888i <br />