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Burnett County Office of Zoning Administrator d M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> o s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y s <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. <br /> tions of the State of Wisconsin. o <br /> m m <br /> w � <br /> Robert Boyer Donald Daniels o O <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> 9408 Park Hunt Court pr1 Rny 316 1 m o <br /> Address AddressOn <br /> n <br /> Springfield, VA 22153 Siren, WI 54872 J <br /> City,State,Zip Code City, State,Zip Code <br /> 703-440-8651 W -O NN <br /> Telephone Telephone Permit(s) to Applied for: o <br /> New Building Filling/Grading m <br /> 's <br /> Addition Moving o <br /> Sanitary x Camping Unit o <br /> Privy Subdivision 5 »- <br /> � m r <br /> Structure Use: <br /> (family home/cabin, garage, addition,etc.) o <br /> m N <br /> Directions for plot plan drawing: L <br /> 1. Show the location and size of all existing buildings(EB) and all new buildings(NB)and indicate North (N). fJ <br /> 2. Show the location of the well (W) septic tank(ST), and drainfield(DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream,- if within 300 ft. , <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, lCy <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. <br /> is form) O as on ax statement.emen . o <br /> PLOT PLAN .a 11N <br /> Z v <br /> P a <br /> )--C,S E E A T T A C H E D <br /> fJ Dw <br /> r <br /> Q, r <br /> rri N <br /> I 0 <br /> 0 <br /> J <br /> m <br /> O <br /> n W <br /> OJ <br /> T <br /> N <br /> V Z <br /> O <br /> Z <br /> I <br /> in <br /> X rnUI DD00-0 <br /> m <br /> a m a� ''I m aam <br /> N O J V7 <br /> Z O <br /> .8 <br /> ms's m <br /> o c i i C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of myS: ; m <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a c <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE 7/13/69 <br /> (si at a of owner or ding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> -n <br /> ✓j TOWNSHIP PERMITS MAY BE REQUIRED ? o. 000Nm <br /> a l0009ca <br />