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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -o -40 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> ,v <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 oN <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. y �_ <br /> o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> m <br /> m <br /> Address Address <br /> v <br /> City State, C✓ r City, State,Zip Code <br /> Telephone + /// D Telephone O <br /> I Q�e <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) O o <br /> Permit(s) Applied for: o °. <br /> `^ r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Zo T <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: 64ND) ' (�' ' ' 4 On k� C) W r <br /> (family home/cabin, garag , addition, etc.) N <br /> 0� <br /> DIRECTIONS FOR PLOT PLAN DRAWING: O rfl Z_ <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). n <br /> 2. Show the location of the well (W),septic tank (ST),and drainfleld (DF). C 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream-if within 9 Z rn <br /> 300 ft. Z <br /> o <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 <br /> to lake, river or stream, If applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C 1 <br /> dated by the owner. m _V_- <br /> PLOT <br /> PLOT PLAN <br /> - <br /> �� C. A <br /> J <br /> LA <br /> a <br /> O ti <br /> N 1 <br /> I Z <br /> ab <br /> C <br /> D NNv (nr DD O <br /> o c . m m m o- F m <br /> m <br /> K= ' =R Km a- a M <br /> a = - <br /> � <br /> 0<. � 'z N O J ,O <br /> Z mp Z 42 1 <br /> f J N M <br /> m <br /> 8 <br /> m c C <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- w m v+ O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 m <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g 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 u, <br /> access to the abo a escribed premises at any reasonable time for the purpose of inspection. m g M <br /> m v m <br /> a <br /> SIGN HERE <br /> (signature ofor building contr c 0 (date) <br /> p S : [ <br /> ZONING ADMINISTRATOR8 . <br /> OWNSHIP PERMITS MAY BE REQUIRED <br /> 9 988rm) <br />