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C ; > i; <br /> Burnett County 7410 Cu. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d a 0 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 c <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 3 a <br /> regulations of the State of Wisconsin. H m <br /> Jim Simons Donald Daniels (::7 <br /> n E O <br /> OW I se Pri Con r or yor or Agent o D <br /> "3806 Inge on Rd ���ox�l� <br /> m <br /> Addrss Address <br /> hell Lake WI 54871 Siren WI 54872 C� <br /> City, State, Zip Code Cry, State,Zip Code <br /> 715-468-7173 715-349-5533 <br /> Telephone Telephone <br /> 23677 Poauette Lake Rd c� <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> 0 C) <br /> 0 <br /> Permits)Applied for: - � �- <br /> �^ r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v <br /> Z a <br /> Accessory Building Sanitary x Privy Subdivision ° <br /> Garage \ It�O <br /> Structure Use: �n i-carq O Ij� ) "'' aJ o <br /> (family home/cabin, garag , ddition,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). O o <br /> 211 <br /> .Show the location of the well (W),septic tank(ST),and drainfield (DF). a3 v, <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building Z cc <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 m <br /> dated by the owner. C <br /> PLOT PLAN M <br /> m <br /> See attached State approved plan <br /> o <br /> o � <br /> N <br /> I <br /> S <br /> >n F m <br /> W. Dam marry <br /> Z mp l m z 1 <br /> ° f S '-! N M <br /> m <br /> 8S �� : i 5i <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S 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- u m�s 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. 1 8 m g <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 <br /> O ' O <br /> access to the above described premises at any reasonable time for the purpose of inspection. `: m 8 g <br /> " -2AH <br /> � a m <br /> SIGN HERE ' <br /> (sign u of own uilding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REOUIRED 1 o o `d m <br /> 8 $ 8 8 $88 " <br />