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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m c <br /> APPLICATION FOR — LAND USE — PERMITS d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 'Z m <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 Slate oofftWisconsin. /� / d <br /> 1411Y'Il �El�)�U� le- rtDY" 0 o <br /> O R (PI ease�ri�t1 Contr5LYor or SurvSury ornt o <br /> ,x" , 7 m_ <br /> Address <br /> City, State,Zip Code's City, tae,Zip Code <br /> 6�^ %13 C <br /> Telephone Telephone <br /> `Ybfl'l4 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) q <br /> `l <br /> Permitos)Applied for: 0 <br /> m r <br /> Dwelling Addition Filling/Grading Camping Unit o c <br /> v <br /> Z0 <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: �✓� �/ l )f—JUC I 1�'1 C o, r <br /> (family home/cabin, garage, add n,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). 0 <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 3 <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)buildingz v <br /> measurement to the ordinary high water mark of lake,stream,or river. 11 11 o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 5 y <br /> dated by the owner. m p 0 <br /> C 1 <br /> PLOT PLAN <br /> 1 � I <br /> 0 <br /> � m <br /> N <br /> O <br /> m <br /> O � <br /> N <br /> .n <br /> Z <br /> D N N V N r D➢ p er <br /> n E <br /> �. Da4 anN a -00 50 no <br /> � <br /> o f cN: m <br /> moo : O <br /> c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g ' o 1D ; 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- y, m p <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 <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 co y officials charg with administering c unty ordinances or other authorized person to have �, <br /> access to the above clesswe"185098 atay7asonabi a pu pose of inspection. m 3 <br /> m m <br /> SIGN HERE r���� <br /> i ( gn ure b ding con rector) 1 I _- =.-- tdate)- <br /> , <br /> ZONING ADMINISTRATOR,;Z t_ I �' 8 AUG <br /> TOWN SNI PERMITS MAY BE REOUIREf7� ����� fr" $ o o 8 m <br /> " ' ��' 89999999M <br />