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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 0 0 0 <br /> - APPLICATION FOR - LAND USE - PERMITS 3. <br /> m M <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 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 3 a <br /> regulations of the State of Wisconsin. w m <br /> Ba-1an WeidendoAA a ° <br /> E <br /> OWNER (Please Print) Contractor or Surveyor or Agent o C� <br /> Rt. #1 Box 205 <br /> � > <br /> Address Address h <br /> Mona, MN 55051 �! <br /> City,State,Zip Code City, State,Zip Code , 70 <br /> (612) 679-5218 <br /> Telephone Telephone 1 <br /> Emergency/Fire No. and Road Name r <br /> Lot 4 CSM Volume 13. Py. 156-157, Section 24, T41 , R17W. Town of Swim <br /> Legal Description (as Indicated on tax statement) ° t� <br /> n L) <br /> Permit(s) Applied for: 0 <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit S o <br /> v <br /> z o <br /> 0 <br /> Accessory Building SanitaryPrivy Subdivision $ >j <br /> Garage <br /> — Pd teT <br /> Structure Use: San2twu n2 /yn <br /> 0 <br /> (family home/cabin, arage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) r0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O o <br /> 2. Show the location of the well (W),septic tank (ST), and drainflaid (DF). 3 <br /> 3. Show dimensions infeet ofthe following:(a)building to all lot lines,(b)building tocenter line ofroad,(c)building MZ a <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 H. <br /> dated by the owner. C <br /> PLOT PLAN m �i <br /> w <br /> N <br /> SEE ATTACHED <br /> z <br /> 1 � <br /> f <br /> o c m a F -MV <br /> a <br /> o E0 <br /> a <br /> m <br /> rr.1 g ! M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my for a. 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 informs- w m H O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 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 $ m 8 <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- y, <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $A <br /> m 33 <br /> Wade Ru6zho2m 3/24/92 " $ <br /> SIGN HERE l <br /> (signature of owner ildin ontra (da 1 o x <br /> ZONING ADMINISTRATOR e $ <br /> M � NNHT <br /> 8 8 <br /> TOWN IP PERMITS MAY BE REOUIRED o , 8m <br /> 'o SS m <br /> 8 <br />