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t C0rye, <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and � io <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 /> regulations of the State of Wisconsin. .� -,� m ` <br /> 00(_ <br /> OW (PI se Priy,� �. Contractor or Syrveyor or A ant o <br /> ,� / f 1 ) yey n ,o 0L) l-r�e, S <br /> Addre s ,_ Addrgss <br /> - Pa�.I, (Y�� S�113 ne'ri a)+_ � (�1 <br /> City, State, Zip Code ' City, ate, Zip Code Cl <br /> 1 <br /> Telephone Telephone -� O <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> ° o <br /> Permit(s) Applied for: <br /> w r <br /> Dwelling Addition Filling/Grading o <br /> Camping Unit � <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <<� <br /> 1A � <br /> DIRECTIONS FOR PLOT PLAN DRAWING: <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 (W),septic tank (ST),and dralnfield (DF). C 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within ? <br /> 11 bo <br /> 300 ft. o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m 0` <br /> to lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C t\ z <br /> dated by the owner. m ' S <br /> PLOT PLAN <br /> 11 <br /> r 1 I <br /> w <br /> (�j 0. <br /> 7 <br /> o � <br /> N J > J 1 <br /> o c m m o a g m <br /> jLKme R 12 M <br /> a< mo0. a3 <br /> Z I : 0 Q - 1 <br /> 0 n M <br /> � c <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g m `� 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- <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 <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 O 0 <br /> access to the above described premises at any reasonable time for the purpose of Inspection. m $ <br /> n <br /> N A x <br /> SIGN HERE <br /> (signature of owner r building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> w <br /> TOWNSHIP PERMITS MAY BE REQUIREDHoi o o d m <br /> $ 8888888ai <br />