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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m mo <br /> APPLICATION FOR - LAND USE - PERMITS3' <br /> m <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 m C <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 <br /> 0 <br /> regulations of the State of Wiscon <br /> / w <br /> �l�( C f <br /> O <br /> WT <br /> e �, Contractor or Surveyor or Agent I%Lffi o A <br /> Idr 1 - � � �� ) I 1 T Address <br /> ~City, tate,_ Zip Code lJ City, State,Zip Code <br /> Tele Telephone <br /> Tale <br /> No. and Road Name L� <br /> Legal Description (as Indicated on tax statement) <br /> O <br /> ) <br /> Permito -C.s)Applied for: H <br /> r <br /> Dwelling �ing/Grading Camping Unit <br /> 0 R <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision °_ } <br /> Garage C 71 <br /> r <br /> Structure Use: g <br /> (family home/cabin,garage, etc.) ,* <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). 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drairttleld (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building an 11c n <br /> measurement to the ordinary high water mark of lake,stream, or river. <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. C I <br /> PLOT PLAN IMII <br /> 0 <br /> m <br /> O y <br /> w <br /> 2 <br /> xoc maoa } m <br /> zea <br /> o < � ,2g000Z23 ; <br /> o : <br /> o ' 2 m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c - m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- ` f ` m t7 <br /> lion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 1r m u <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 $ 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- . r ; <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to haveN ,\ : [. m g , <br /> access to the above described premises at any reasonable time for the purpose of Inspection. B if <br /> ^ a <br /> CJ <br /> SIGN HERE (date) _ <br /> (signal of owner or building contractor) ' <br /> o ; <br /> ZONING ADMINISTRATOR ' <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o m <br /> 88F� 8$ 8ro <br />