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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator c a <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 <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. 1 H o <br /> A �/pn A. �onnc/ Jr. � n O <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> >ao OoX 4/3I <br /> Address Address 1 <br /> t&�' .c-- . <br /> City, State,Zip Code City,State,Zip Code <br /> LLL-b <br /> Telephone Telephone <br /> 8GL - H3.5a <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> n L) <br /> Permit(s) Applied for: o` <br /> Dwelling Addition Filling/Grading Camping Unit °- <br /> 7 <br /> 0 o (U <br /> Accessory BuildingSanitary Privy Subdivision <br /> Garage / - <br /> Structure Use: c�<,E _ eo s-6 iyG ��_ / �X <br /> (family home/cabin, garage, addition,etc.) I J <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). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). an 3 <br /> 3. Show dimensions in feet of thefollowing:(a) buildingtoall lot lines,(b)buildingto centerlineof road,(c)building an <br /> Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. o �n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m J m <br /> dated by the owner. <br /> PLOT PLAN 10 9 <br /> +f <br /> 1 <br /> C) <br /> _See <br /> N <br /> O C <br /> m <br /> O � y <br /> Hj <br /> d <br /> V Z <br /> ISS <br /> $Doc - W0 � c, <br /> n+ m <br /> m 2. <br /> D sC 0 a <br /> Z m c m .2 1 <br /> 0 <br /> fes ; Tm € m <br /> E <br /> 8 : rn <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- i j = 00 <br /> a is 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 g m <br /> further accept all liability which may be a result of the Count of Burnett relying on this information 1 am providing in this a <br /> P Y Y Y Y 9 P 9 P' <br /> plication.1 agree to permit county officials charged with administering county ordinances or other authorized person to have c, <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g m <br /> N ^ a <br /> m <br /> SIGN HERE <br /> (sign a of o or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNS IP PERMITS MAY BE REOUIRED MAR I I OR ^� E �'N )5 m <br /> `B N N N N O O <br /> ggggBggN <br /> + <br /> i <br />