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�1 <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 - PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 14 <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 J <br /> 0 <br /> regulations of the State of Wisconsin. y 9 <br /> OW <br /> N ase P int) Contractor or Surveyor or Agent o m <br /> 157 7L <br /> Addres Address (2) <br /> ,��G�)inrn� <br /> City, S�ate,Zi Code T City, State, Zip Code (� <br /> ( o/ 5-7/-/CL's 7 <br /> Telephone Telephone ) <br /> E r ncy/Fire No. anp Road Name <br /> / �°SIY) Lly/ of, %4)�(/ C&a <br /> Legal Description (as indicated otax statement) <br /> n L) <br /> 0 <br /> Permit(s) Applied for: $ »- <br /> m � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy SWpdivision P } <br /> Garage N` <br /> Structure Use: /� <br /> (family home/cabi , garage, add' Ion, .) <br /> 71 <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). 9 0 <br /> 2. Show the location of the well se S (DF). 3 <br /> (VV), ( T),and drainfield <br /> m <br /> septic tank In <br /> 3. Show the location of any lake or flowage- H within 1000 ft. and the location of any river or stream- if within Z `v <br /> 300 ft. o o I <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building o <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 I <br /> dated by the owner. m <br /> PLOT PLAN <br /> 1 <br /> I <br /> I <br /> m <br /> O � <br /> w <br /> I0 <br /> Z <br /> I <br /> 9 /n 7i � rn � D Dv <br /> 9 <br /> OZ 0 0 M <br /> f T n: m <br /> N G) <br /> p O C <br /> m m : <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> M 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- t w O <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 $ m $ <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- w <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m $ 10 <br /> 3 A <br /> SIGN HERE `S <br /> (sign re of owner or building contractor) <br /> ZONING ADMINISTRATOR " <br /> HT <br /> TOWNSHIP PERMITS MAY BE REQUIRED N o T . m <br /> 888 8888M <br />