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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ED m m 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 '2 w � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. _C / w m_ <br /> ✓® vf�N n m F <br /> 0 N�ES�++ (Please P int) Contractor r Surveyor or Ager o . <br /> 5�7? �02 `� Z±P 73 C 7zi 2cf z�v 7, <br /> Add Iess AM <br /> �j:o D/1f5an/ MMS qJ d <br /> City,State,Zip Code City,State,Zip Coder 23 <br /> � 7So `f 4"66 - ;V 7// 6 ! <br /> Telephone 7 Telephone — <br /> ,5-0 3 7 76 U' 70 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) 1� <br /> n 0 <br /> Permits) Applied for: o °- <br /> 0 <br /> � L <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: are'ni o <br /> (family home/cabin, garage,addition,etc.) <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 dralnfield (DF). 3 <br /> 3. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building � Z v <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and M <br /> dated by the owner. <br /> C <br /> PLOT PLAN m r, <br /> f N <br /> o <br /> N <br /> o � <br /> m <br /> o y <br /> 7j <br /> m z <br /> Xl//Jn/l i <br /> f <br /> o c a m n F T <br /> m, Dnp m 'aom = y <br /> < in N O m <br /> Z m o <Q : 1 <br /> a M �0' i m <br /> I"ni mac ; p <br /> 8 Am € a <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 /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- a m 12 O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 'm In <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 ut <br /> n ' <br /> access to the above described premises at any reasonable time for the purpose of inspection. B 3 8 0 : <br /> A m <br /> SIGN HER <br /> (si of owner o Iding contractor) (date) '\ ` a <br /> ZONING ADMINISTRATOR g <br /> N N S <br /> TOWNSHIP PERMITS MAY BE REQUIRED N u b o o 8 m <br /> 88888888rmo <br />