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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. 0 <br /> 0 <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 m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> re ulations of the State of Wisconsin. T ,� <br /> N N <br /> TjP 'r '01 a o <br /> WNE Please Print) Contractor or Surveyor or A/gent o <br /> .S/lm � <br /> Addre Address 1 <br /> City, State,Zip Code City, State,Zip Code p� <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name i <br /> Legal Description (as Indicated on tax statement) <br /> n L7 <br /> Permit(s) Applied for: o �- <br /> N O <br /> Dwelling Addition Filling/Grading Camping Unit S <br /> v <br /> = o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> s�jr�e.(/ A)1-Structure use: 0 N- � o <br /> (family home/cabin,garage,addition, etc.) <br /> R <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M I ^ W <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 drainf laid (DF). 3 <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building Z `v <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 y <br /> dated by the owner. C <br /> PLOT PLAN i/ / �� /?OkTulE y► C�} <br /> Orr <br /> aQ, <br /> r <br /> N O <br /> co <br /> ri .c <br /> N. <br /> O O <br /> � O m <br /> �r4rd <br /> Z <br /> yo/ r4 <br /> . � I1 <br /> �ta(au�idt� � Df <br /> m <br /> 5 D� a 'aNoma <br /> o mZ <br /> mai m <br /> c <br /> 1 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 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- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 , 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 N g <br /> access to the above des cri premises at any reasonable time for the purpose of inspection. m 8 <br /> m 3 <br /> N � O <br /> SIGN HERE 'f a <br /> (signature of n or building n actor) <br /> ZONING ADMINISTRATOR <br /> T NSHIP PERMITS MAY BE REQUIRED <br /> ,il "128888888y <br />