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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m Io 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Q <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the a m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0. <br /> regulations of the State of Wisconsin. H <br /> N <br /> J'ftr1�S A. lV v(zn ( %vM GvEQQ 2 . a o <br /> f <br /> OWNER (Please Prim) .n Contractor or Surveyor or Agerlt o <br /> oZ(O tl CL/fG(Tll(�w U2 ,2Yo 5 1,L~F- ,fid , m <br /> Addr ss cAddress <br /> / As nti� !�M(titi 55 0 33 w .3S2 . wiJ c SYS `1 y�J <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Emergent Fir�f N&8 <br /> n <br /> .�,d Road Name <br /> s� lB .sn,_ l r3g�v - �f�W parr o. <br /> Legal Description (as Indicated on tax statement) R <br /> Permit(s) Applied for: o` <br /> Dwelling Addition Filling/Grading Camping Unit o °^ <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage/T <br /> Structure Use: <br /> 0 <br /> (family home/cabin,garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). M <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 3 <br /> 3. Show dimensions Infeet of thefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building � Z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and y <br /> dated by the owner. fA <br /> C f <br /> PLOT PLAN m <br /> ,.L <br /> S <br /> - - <br /> 0 <br /> m <br /> w Z <br /> I <br /> v D O c .0 d 6 F <br /> mMM <br /> p 6 a N 0 <br /> N O J ,O <br /> m <br /> 8 i mom : c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o '°m <br /> m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa. <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g 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- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above d ed premises at any reasonable time for the purpose of inspection. m 3 8 <br /> m gypyp a <br /> SIGN HERE <br /> ignat o owner orb g contractor) (date) o s <br /> ZONING ADMINISTRATOR C. a I g <br /> TOWNSHIP PER ITS MAY BE REQUIRED o 8 m <br /> 99999 88 (a <br />