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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 70 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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 o p` <br /> regulatio of the State of Wisconsin. <br /> OWNER (Please Print) J 6e{ a0 r or�urveyof o�gem o <br /> {F `j yo C� <br /> Jj <br /> Addres _ Adpres I- ',,PI <br /> �l 1P�af��� �110�i7 I� �� I <br /> City, State,Zip Code city,St te,Zip e LJ <br /> �`6 - loa STr) Co12 i <br /> Telephone Telephone <br /> 7 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) ° <br /> Permit(s) Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit S ? <br /> J <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o } <br /> Garage <br /> Structure Use: 0 <br /> (family home/cabin, garage, addition, etc.) I g <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O c <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). .n �3 w <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building .0 Z Q <br /> measurement to the ordinary high water mark of lake,stream,or river. d 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 /> I <br /> PLOT PLAN m , <br /> � � <br /> C,� 1 -C. <br /> f1a �� <br /> c* <br /> N <br /> (wry C <br /> Z <br /> f <br /> � o� � mm �ag � <br /> M <br /> m Da,� m.nN am 70 <br /> < ` : m o 0. 21 ; <br /> Z A° m Q i <br /> F T N M <br /> _ m <br /> 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 /> 1 <br /> $ m '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- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 m u' <br /> Mallon I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I �y $ A $ <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- V �, <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have 0 0 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ $ <br /> r 3 <br /> ro V A w ! <br /> H N <br /> SIGN HERE <br /> H: D <br /> (signature of owner or buildingcontractor) (date) <br /> ZONING ADMINISTRATOR <br /> � w`j uwa ,1 <br /> TOWNSHIP PERMITS MAY BE REQUIRED Zr^ N $ o ,o f5 m <br /> 8888888 $ rmn <br />