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:tt County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator CA 'o -+ z <br /> APPLICATION FOR — LAND USE — PERMITS F <br /> 3 � <br /> FHE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y ° <br /> sated as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the CD m <br /> urnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. - o <br /> H � <br /> e L D <br /> OWJFR Please Print) Contractor or urveyor or Agent f <br /> _ J �/� W 6 s� s� S7. 1 S'3/ CD <br /> Adss <br /> dre <br /> M�Y � �d� tv /72,nSSO�Z A/��v)Jan <br /> City, State, Zip Code Ci State,Zip Code (Tl I <br /> Telephone y 35 Z7'rl5 //s _E -7 6 sy Z <br /> Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: ? c <br /> o < <br /> N <br /> welling Addition Filling/Grading Camping Unit o <br /> Accessory Building _ C Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: 20 ?( 2 2 f 8 <br /> (family home/cabin, age, addition, etc.) 0 <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). <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 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 ? rn <br /> 300 ft. Z <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 <br /> to lake, river or stream, if applicable. M <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C o <br /> dated by the owner. M ' <br /> PLOT PLAN M 6 ` <br /> 2 py pil I 3 <br /> - - -- � C, <br /> CD <br /> 17fi <br /> N <br /> Sd f m l/r <br /> Z <br /> �G;ht <br /> co oin � mag „ <br /> �-�°. Dai '- cN am <br /> i CNo � � <br /> � COD ;02 ,m <br /> ° ` <br /> m <br /> N 2 O <br /> c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o C <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- y, ci- M <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m r,'.) <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I m <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 time for the purpose of inspection. "8 <br /> N <br /> ^ N : <br /> f/ / A <br /> SIGN HERE y�slof m 8 <br /> N <br /> (signature of owner or building contractor) (date) a <br /> �m FLflNlhfl x <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED ZAN � No o' m <br /> 8888888 $ x, <br />