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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 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 � m <br /> s <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 n Q� <br /> regulations of the State of Wisconsin. w m <br /> '4tv�y tau Si.�en/ d.lr>Vh _S a 0 0 <br /> OWNER Millase Print) Contractor or Surveyor or Agent o m <br /> Address Address <br /> sl�`l1.att.n jyi Lg- ,1s'Vin a J� <br /> City,State,Zip Gie — City,State,Zip Code <br /> 915 , q s <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name ^ <br /> Legal Description (as Indicated on tax statement) o <br /> �J <br /> n G) � . <br /> Permits) Applied for: a IC <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building - Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: s <br /> (family h me/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 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). 03 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 91 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 f7 y <br /> dated by the owner. M <br /> C 91 <br /> PLOT PLAN <br /> -- — S <br /> i <br /> �bo <br /> CIS <br /> V <br /> a° <br /> r Sewcrz N <br /> f M o <br /> 1q <br /> Q v I n <br /> PARA aO <br /> i <br /> T I o c � mym tD+ 6g9 <br /> J' h v m '<" cmbo 3 <br /> IDs <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- om it: 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- <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. 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.I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described premises at any reasonable time for the purpose of inspection. m30 g P <br /> yyA u <br /> SIGN HERE <br /> (signature of owner of uil ng c tract (date) X� ; <br /> P : <br /> ZONING ADMINISTRATOR /nom g <br /> N <br /> TOWNSHI PERMITS MAY BE REQUIRED xrn rN o o�d m <br /> 88888888rmn <br />