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rl{ - <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (no 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all workshall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations J of the Smtate of Wisconsin. V H �_ <br /> Do <br /> Qj <br /> OyWN�EyyR (Ple a Print) /✓ Contractor or Surveyor or Agent o <br /> �)_Ifndq(f' lel <br /> Ad r ss Address I <br /> City, State, Zip Code City,State,Zip Code <br /> 7lc'-- -��— �nq4 <br /> Telephone Telephone - <br /> a�c�-� <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> n L) <br /> Permit(s) Applied for: o <br /> Dwelling Addition Filling/Grading Camping Unit S ° <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage / <br /> Structure Use: <br /> (family home/cabin, gara addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <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 drainfield (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 <br /> 300 ft. an o a <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building H <br /> to lake, river or stream, if applicable. m 0 <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. m ' <br /> PLOT PLAN <br /> I <br /> o <br /> o <br /> o . ro 3 <br /> P <br /> P M <br /> = m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my know[- 0 <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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- m N <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 8 <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. w 8 <br /> d V A N <br /> SIGN HERE <br /> (si ure ner wilding contractor) (date) '. � ; �, <br /> o : <br /> ZONING ADMINISTRATOR g <br /> N NON�� t�li m <br /> TOWNSHIP PERMITS MAY BE REQUIRED v, v, u, v, o o , m <br /> 88888888vmi <br />