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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ,U+ m 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 m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the C <br /> Burnett County Land Use Ordinance, Sanitation Code, and with ail other applicable County Ordinances and the laws and 3 a <br /> regulationsof the State <br /> of Wisconsin. H m O <br /> AJ I C A,o O <br /> OWNER (Please Print Contractor or Surveyor or Agent m <br /> .S 4eW A/ m <br /> A rens r Address <br /> wv btl <br /> City, State,Zip Cod City,State,Zip Code — <br /> 7 R9 <br /> /s - & --Sb3 ) bsr`r- 0yo.3 <br /> Telephone Telephone i <br /> I 11 $S C Y05S*04d.v <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> i <br /> 0 <br /> Permits) Applied for: 0 �- <br /> r <br /> Dwelling Ad ' Grading Camping Unit v E <br /> Z o <br /> Accessory Building Sanitary P Subdivision 3 <br /> Garage <br /> Structure Use: - O o <br /> amity ho /cabin, garage,addition, etc.) 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O o <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). an cv, <br /> 3. Show dimensions In feet ofthefollowing:(a)building to all lot lines,(b)buildingto center line of road,(c)building Z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o a •1� <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. C 1 0 <br /> PLOT PLAN ^�vJ m <br /> N <br /> m <br /> n <br /> 0 <br /> Jpp <br /> o I 1 J <br /> J <br /> J <br /> O � <br /> — ICIO <br /> Z <br /> y <br /> N <br /> m o� � U"w V <br /> c <br /> Doro N �' _ 3 <br /> G e. 'Z N O J (p <br /> P F 0 TZ i <br /> ? i m <br /> u [ OoE O <br /> A a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of Il knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- qq!!m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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. I $ m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to ha 0 o , <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ m <br /> r i 3 n <br /> m V A n <br /> D N 8H x <br /> SIGN HERE a <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR -Zfi'rn <br /> TOWNSHIP PERMITS MAY BE REQUIRED .N 1 0 NoSm <br /> 888 8889 GO) <br />