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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Pu � o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> u <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v y <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 /> 0 <br /> regulations of thip State of Wisconsin. <br /> M o <br /> n f <br /> OT (PI Print) Contractor or Surveyor or Agent v m <br /> Address Address <br /> A . <br /> City, State, Zip Code City, State, Zip Code <br /> 17�J <br /> 3 G 5 <br /> Tel phone Telephone <br /> Emerge y/Fire No. and Road Nam <br /> Nw F Sae 32 yONR /6G� Da ©oxX ' <br /> Legal D scription as indicated on tax statement) 2-$' Aft o <br /> 134�wQ�Cf9 � o° W <br /> Permit(s) Applied for: ° <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit 0 o <br /> Z vo <br /> Accessory Building Sanitary Privy Subdivision ° $ <br /> Garage <br /> Structure Use: // 'P e 4 ej u / o <br /> (family home/ abin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O <br /> 2. Show the location of the well ,septic tank S (DF). 3 N <br /> p ( T), and drainfleld <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within on , `C <br /> 300 ft. 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 A to lake, river or stream, If applicable. m o <br /> 5. 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 A-Z <br /> PLOT PLAN ( _ <br /> Q <br /> 1 <br /> K o <br /> 0 Illll J�1/1 <br /> m <br /> y <br /> Albwad rw <br /> See 2-o- <br /> .S <br /> mcn � m � naoM <br /> 9 <br /> Zm Q m Z M <br /> P F o b ' =! !n i M <br /> N D Rr. N11) IA r WArC2 / A1 T�fF/a�r2 _PC � Nio C <br /> o 0, <br /> M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- — 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- .n w yr O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- N <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 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- (n <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have ct v"', O <br /> access to the abo cribed pr mis at any reasonable time for the purpose of inspection. m 8 00 <br /> m 3 n . <br /> m a y m <br /> » 8 : <br /> u4 .23 IV 20 N : <br /> SIGN HERE <br /> I at a wrier r a contractor) (date) o . x <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERM S MAY BE REQUIRED v N v 'o m <br /> 89 9 88rp <br />