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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm 0/ 0 7 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> w o <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 m C, <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n <br /> regulations of the State of Wisconsin. <br /> Orren Luctv&- mau- lkr'uw a01 <br /> OWNER (Please Print) S Cope cSv <br /> Ad ress ��'yyD � // Addreps }� K <br /> City State, ' p Code City,State,Zip Code <br /> 1,�; S <br /> � - 4�2yn <br /> Telephone Telepjlone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o O <br /> Permit(s)Applied for: o °. P <br /> tj{I— <br /> Dwelling Addition Filling/Grading Camping Unit ° <br /> v <br /> Z <br /> Accessory Building Sanitary Privy Subdivision o m <br /> Garage <br /> Structure Use: o <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). M n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within -P <br /> 300 ft. Z <br /> o n <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building () <br /> to lake, river or stream, if applicable. in .. <br /> S. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. m <br /> PLOT PLAN w <br /> Csrq. <br /> vI <br /> o <br /> J <br /> II m <br /> 1P Q sm ^ <br /> ev+e 4; v <br /> 1) hd+ a- hus MtfjIfK -t bu'lJ,r c Are-0. wtiLh Wdi resirll+ <br /> Std -F oi-- bu le�vgs ro z <br /> 0 70 <br /> 4 <br /> a� /Vori aA ",bh wA I.u.c AnS b'lhowry �.. C-SM ,s vof <br /> -14e Drcltna� ll.�1 tuate,-- MAIK uscrj So r+�ecerurrw� sQ bAcks. <br /> .3� max . dull+ LJId( of aver ow L.-t a . Th s wool /,w�l�4e p <br /> on c m m0a Go M <br /> o a F m <br /> 14 50+-6A4(k p U e.ttTo„ m f <br /> U�C.ri[(r[.QS W• �(,ot be G4 ray- Cpc 'o < °' C H 3 <br /> o m <br /> U Z Grn; _ 'z " pro <br /> m <br /> C <br /> ac C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- e 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- w m O <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 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 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m $ <br /> D V A x <br /> N m A <br /> H in 8 : <br /> SIGN HERE d' a <br /> (signature of owner or building contractor) (date) o x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED n a 8 o 8 m <br /> 888888880 <br />