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;7410 Co. Rd. 1 #10Z Siren WI 54872 <br /> Burnett County r Office of Zoning Administrator w '0 � Z <br /> APPLICATION FOR — LAND USE — PERMITS 3 p <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'Z <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c IN <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�f Wisconsin. 3 o �� <br /> /a2` l 211&10 o <br /> OWNER(Please Print) Contractor or Surveyor or Agent n <br /> 1142 lZcoo .vfdi�t c ° <br /> Address L4Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone 67�.� /p(,Y Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit n c> <br /> 0 <br /> Privy Subdivision 0 <br /> r <br /> Structure Use: �Cl�' ° <br /> v <br /> (family home/cabin,garage, addition,etc.) o e° <br /> m <br /> Directions for plot plan drawing: n <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). <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. o <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, <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. 6. Provide legal land description. o <br /> PLOT PLAN ° <br /> 3 <br /> P N <br /> Z v <br /> o n <br /> N <br /> O <br /> v ' n <br /> f�c>v�ey l� kP <br /> � o <br /> V) <br /> ° <br /> aDo 0 <br /> N <br /> O — <br /> b <br /> O <br /> O <br /> 9 Z <br /> t_ II <br /> Z <br /> 33 o <br /> I lx/ <br /> M tnvmr a)-0 <br /> A nom '-'nm c 10 <br /> am 3 <br /> Z 0 <br /> nom: Cc C) <br /> of <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m C <br /> PP ( 9 y ) Y ll g ! E m ! 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 an accompanyingschedule and I furtherdeclare that I recognize that <br /> PP (� 9 Y 1 9 ! C <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <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 remises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE Z "' <br /> (si re of owner ui ing contractor) (dat <br /> .ONING ADMINISTRATOR �:4 o o <br /> i J N O I V N T <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0oF1 m <br /> 00000 y <br />