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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m c ro <br /> APPLICATION FOR — LAND USE — PERMITS 03. ' <br /> o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the W <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and - o. <br /> regulations of the State of Wisconsin. d `� <br /> 0 f <br /> (Pte a Pri Contractor or Surveyor or Agent \m <br /> q 4 <br /> �lri!U71G� �WI -113 Address <br /> City,State,Zip Code City,State,Zip Code _ <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> c> C <br /> 0 <br /> Permit(s)Applied for: <br /> m � <br /> 0 <br /> Dwelling Additi Grading Camping Unit <br /> Z 1 <br /> Accessory Building Sanitary Pr' Subdivision _ } <br /> Garage <br /> Structure Use: r ` <br /> (family home/cabin, garage,addition,etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 2 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). O a <br /> 2. Show the location of the well (W),septic tank(ST),and dralnfield (DF). on3 <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building = c <br /> measurement to the ordinary high water mark of lake,stream,or river. ` n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and o <br /> dated by the owner. <br /> PLOT PLAN <br /> I <br /> p <br /> 9 <br /> /C <br /> f v 1 r/1 <br /> N I <br /> O y <br /> N <br /> Z <br /> I� <br /> ro c m m o n g m <br /> 00 <br /> ZON.m m .Z •� <br /> m <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- o ' m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informa- <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 i [ $ o $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this ap- <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized penton to have ? :. 4 <br /> access to the above described premises at any reasonable time for the purpose of inspection. B $ $g <br /> SIGN HERE <br /> (signatu of owner or building contractor) (date) <br /> o : <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIREDy o o m <br /> 888 <br /> 8 $ $ ro <br />