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Burnett County 7410 Co. Rd. K, No. 102, Siren, Will 54872 Office of Zoning Administrator » a r a <br /> APPLICATION FOR — LAND USE — PERMITS 3 3 <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 /> reg lations of the State <br /> -of Wisconsin. <br /> O <br /> O R (Pleas Print) Co ctor or Surveyor o Agent o <br /> + .. <br /> . fo , t"�t �C� <br /> Atltlre Address �� I <br /> nWef'rn� ISL �5Z/��� U)PbS�Ai; <br /> City, State,Zip Code City, State,Zip Code ) ; <br /> , <br /> Telephone Telephone ) ) <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) ° < <br /> n O rtj <br /> 0 <br /> Permits) Applied for: 0 <br /> N � <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> 0 <br /> (family home/cabin,garage, addition,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). » <br /> 2. Show the location of the well (VI),septic tank (ST),and drainfield (DF). 3 v, <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. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed andm 9,) o <br /> dated by the owner. C I 0 <br /> PLOT PLAN w <br /> I <br /> CJ <br /> 0 <br /> o <br /> o <br /> J <br /> a <br /> I <br /> Mo c NN d tDi OD. m <br /> o f 0 T� <br /> m <br /> Oma : O <br /> C <br /> R <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- M <br /> S 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- w m O <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 g m g <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 <br /> C) o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 80 <br /> T i 3n <br /> m v n N <br /> fE : 0 pp <br /> Hm 8 <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) o x <br /> ZONING ADMINISTRATOR � � 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED L" <br /> 88888888ro <br />