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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and a <br /> re ulations 9f the State of Wisconsin. w <br /> f <br /> OWNER(Please rl1 f� Contractor or Surveyor or Agent m 'm <br /> �S(o� rfSl, AUE S. <br /> Addre s Address <br /> C +1-4e,v �,rdf��4V1v� 5501 (0 <br /> City, State, Zi Code City, State,Zip Code <br /> Telephone Telephone t n <br /> M y H 11 <br /> Emergency/Fire No. and Rod Name <br /> Legal Description (as Indicated on tax statement) <br /> O <br /> Permit(s) Applied for: �- <br /> welling �� Additi Filling/Grading Camping Unit S o <br /> Z o <br /> w din Sanitary ` Privy Subdivision } <br /> Garage ) <br /> Structure Use: <br /> (famil h e/cabin,g age, adtlitio , etc.) O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) y� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). o `tom <br /> 2. Show the location of the well (W),septic tank (ST), and drainf laid (DF). � v v, <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building Z `o <br /> measurement to the ordinary high water mark of lake,stream, or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m za <br /> dated by the owner. . C I <br /> PLOT PLAN <br /> /la , <br /> IC <br /> o <br /> INj� <br /> Z <br /> N O c m d D a F m <br /> m. Da•� m aN `:' m M <br /> < ` : •2 m o 3 00 3 <br /> P f .0i a <br /> mac : i m <br /> C <br /> 8 : € Wim: S <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- w m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this in or- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ m 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- w <br /> plication.I agree topermit county officials charged with administering county ordinances or other authorized person to have n N o <br /> access to the abov described pre ises at any reasonable time for the purpose of inspection. m 8 <br /> m V A m <br /> SIGN HERE �Jv _ 3 _ 9 3, <br /> (signature at or uilding contractor) (date) ! o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> Vim m N 0 o 0 08 V o S m <br /> 98 8888rmo <br />