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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d _ O o <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 w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the �^ <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. m m <br /> m <br /> nAI.9 Ll F �f/oCr �i l.� a o <br /> F <br /> OWNER (Please Print) /� //�� �,�, Co7raclor or Surveyor or Agent o 'm <br /> �2Z�L �`/ /nfJ PiNF k,4) !Q1 Tmher5hh(P . <br /> Add ss Address <br /> ros is e GJI S�f�`i3 a�a ✓ /n <br /> City,State,Zip Code City,State,Zip ode <br /> Telephone Telephone <br /> I <br /> Emergency/Fire No. and Road Name S <br /> Legal Description (as indicated on tax statement) <br /> n 0 <br /> Permit(s) Applied for: o` <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> X` / z o <br /> Accessory Building Sanitary f`--'� Privy Subd[iy�+"¢ion ° m <br /> Garage (��m / am; <br /> Structure Use: ( o <br /> (family home/cabin, gar e, addition,etc. — <br /> 1A <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) � <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 9 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 0 3 <br /> an <br /> 3. Show dimensions infest of thefoliowing:(a) buildingtoalllotlines,(b)buildingtocenterlineofroad,(c)building c <br /> measurement to the ordinary high water mark of lake,stream,or river. o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and IQ _' <br /> dated by the owner. C I ° <br /> PLOT PLAN M <br /> 111 <br /> �M4 -Z <br /> i <br /> 0 <br /> N <br /> o i <br /> I� <br /> d Z <br /> 2o c m r. o a F MMm, �a.� m a m 2 m M <br /> C 0, <br /> F c S i Zl N j i 9 <br /> m <br /> N : n C <br /> 8 s m m i a <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o : 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- <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. I 8 e $ <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- N <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have m g <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> T 3 <br /> ^ppp ; <br /> SIGN HERE <br /> (signature of owner or buildi ntr d ) <br /> ZONING ADMINISTRATOR <br /> �+ NMMT <br /> TOWNSHIP PER ITS MAY BE REQUIRED In 8 o o S m <br /> 88 8 $$ 8rmn <br />