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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorf o <br /> APPLICATION FOR — LAND USE — PERMITS o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 N <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 1D m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> 0 <br /> reguI ns of the State of Wisconsin. w <br /> f <br /> OWNE Please PL.rint) Contractor or Surveyor or Agent m m <br /> 4Xf <br /> AdcJress Address <br /> City,State,Zip d City, State,Zip Code 1 <br /> fir-ds� -35�f%3 � <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) `I <br /> ° I <br /> o <br /> Permit(s) Applied for: w <br /> r <br /> o ° <br /> Dwelling Addition Filling/Grading Camping Unit v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) A rJ� <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O <br /> 2. Show the location of the well (W),septic tank (ST), and draiMield (DF). 11 <br /> 3 v <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building on Z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. o 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andZ- <br /> dated by the owner. C t �� <br /> PLOT PLAN <br /> I <br /> 0 <br /> J� <br /> rJJ <br /> Z <br /> i <br /> II <br /> A p c � m r- ? a F T <br /> m - a� znm } my <br /> o 30 3 <br /> Z mem .Z : i <br /> ea : i In <br /> 5 � " c <br /> m <br /> 1 declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- E : O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this in or 8 <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 m N <br /> access to the aboven premises at any reasonable time for the purpose of inspection. x <br /> N '. <br /> M N <br /> SIGN HER x H n <br /> (signature of owner or Duil m c tract ate e x <br /> ZONING ADMINISTRATOR N <br /> TOWNSHIP PE MITS MAY BE REQUIRED �N S m <br /> 88888888r"r <br />