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L\ <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator v m o 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 y <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 a <br /> 0 <br /> regulations of the State of Wisconsin. H m <br /> OWNEPeas Pr i t Contractor or Surveyor or Agent <br /> Address J' Address <br /> L' / <br /> FAIJ �L �I10l svol <br /> State, ode City, State,Zip Code is - �'3 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n L7 <br /> 0 <br /> Permit(s) Applied for: N =- <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o � <br /> v <br /> z o <br /> Accessory Building --� Sanitary P Subdivision i� } <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage,addition, etc.) Mill <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). C <br /> C <br /> oo' <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show dimensions infest ofthefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building o 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 H <br /> dated by the owner. I <br /> PLOT PLAN m <br /> 1 <br /> See QJ,& �lOr PL �J <br /> / N <br /> n <br /> O <br /> J <br /> O <br /> J <br /> J <br /> O <br /> 2 <br /> Z <br /> F,l\ <br /> M D a� it & 00 2: m a <br /> m m Q -1 <br /> f D <br /> Cr m <br /> N cc 0 <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- " v.m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- $ N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ $ <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.Iagree to permit county officials charged with administering county ordinances or other authorized person to have no <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ m <br /> n <br /> / �/,(�/////� <br /> SIGN HERE (date) <br /> (signature - <br /> (signature of owner or bu- g c tract o x' <br /> ZONING ADMINISTRATORlY IJ'UI 1 ----- <br /> Jug (�$b <br /> TOWNSHIERMITS MAY BE REQUIRP go <br /> $o$ 8$ mm <br />