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C;Y <br /> Burnett eounty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator do a <br /> APPLICATION FOR — LAND USE — PERMITS d 3_ <br /> 0 <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 MO m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and _ n <br /> regulations of the State of Wisconsin. <br /> m <br /> F <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> m <br /> Addresss Address C— <br /> K. <br /> K. 7 /. <br /> ity, State Zip Code City,State,Zip Code I Ir <br /> Tele one <br /> hone Telephone <br /> 5"I 3Q MINtJ Inc- 12a _ 3 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> O 4` <br /> Permit(s)Applied for: 0 ° � <br /> m r C <br /> Dwelling Addition Filling/Grading Camping Unit o 0 <br /> v <br /> Z o <br /> Accessory Building Sanitary —7x-- Privy Subdivision P <br /> Garage <br /> Structure Use: AW 1--TRRV OfQw Vj = <br /> (family home/c bin, garage, add ion, etc.) n <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <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). C 3 1 <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within <br /> 300 ft. ona (J <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m SIG <br /> to lake, river or stream, if applicable. <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 /> m <br /> PLOT PLAN <br /> ffjjF�cNEn � m <br /> -1 <br /> �C <br /> St <br /> w_ <br /> 1 2 <br /> Q � <br /> f <br /> m o c C.0 m tDi a m <br /> m y7 a`� mnm am a <br /> a jai 42 o `i �' 3 <br /> 2 Ao <br /> P Fes : NM <br /> _ aa m <br /> L" i � � O <br /> 8 <br /> M <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 infonna- 1 fn m u O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- _. )S ro E <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 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. <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have O <br /> access to the above described premises at any reasonable time for the purpose of inspection. : a 8 <br /> m : A <br /> SIGN HERe <br /> ,��rii, <br /> E.. <br /> (signature of owner or n din ntractoate) o x <br /> ZONING ADMINISTRATOR /v 8 : '. <br /> TOWNSHI PERMITS MAY BE REQUIRED N" Pn 0 o 9 m <br /> 8 �8888rmn <br />