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Burnett County'7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator uA o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3, <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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 a <br /> regulations of the State of Wisconsin, y m <br /> CU RTIS CRNA B �L�� a o <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> Kilo <br /> wll.ES D2 <br /> '9rA G I `, q W Address <br /> City, State,Zip Code X `L City,State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> n <br /> Permit(s) Applied for: 0 o <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit o 0 <br /> Z v <br /> Accessory Building Sanitary Privy Subdivisiono °, I <br /> Garage R f� r U ! <br /> Structure Use: �( <br /> 1 f1�2U — I u klyils Term )gt"ti� U <br /> r <br /> (family home/cabin, garage,addition, etc.) ^ 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 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 ,se ° <br /> (VV) tic tankS <br /> (p T), and drainfield (DF). 3 <br /> 3. Show dimensions in feet ofthefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)buildingan z <br /> measurement to the ordinary high water mark of lake,stream,or river. an o o. <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. fA <br /> C <br /> PLOT PLAN m <br /> d <br /> ) rom <br /> 0 <br /> 0 <br /> o <br /> N <br /> i <br /> Z <br /> i <br /> G <br /> 0 oc M. m m 'D' aF M <br /> - o0 oo. m <br /> o D <br /> K� m o r <br /> 00 30 <br /> Z m p =m .Z : <br /> ° o iN i i m <br /> 8 : C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o i A '� i a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informsmO <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- .8 m u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 A g <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 u, <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> In 3 g m <br /> ro o y H <br /> SIGN HERE <br /> (sig tura of owner or builoin bn <br /> V <br /> ZONING ADMINISTRATOR <br /> it _ <br /> TOWNSHIP RMITS MAY BE REQUIRED MAY 1 1 (992 <br /> m j u o o§ ro <br />