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Burnett,County 741p Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator w -- 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 N m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0. <br /> regulations of the State of Wisconsin. N m <br /> OWNER (please PriD Contractor or Surveyor or Agent o <br /> � m <br /> Ad s j Address <br /> Ciry��nte, Z 5de /-f City, State, Zip Code <br /> I elephone L y Telephone I ' <br /> �rrc!fire . a /Road Napte /� y SQL. '� <br /> / YEJ/L// lac y <br /> Legal Description (as indicated on tax statement) <br /> G) <br /> Permit(s)Applied for: o o- <br /> 'w r <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage �/ <br /> Structure Use: ���( � / Ox, <br /> `Z J o <br /> (family home/ca in, garage, add'ton, etc.) -r <br /> o <br /> DIRECTIONS FOR PLOT PLAN DRAWING: M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). G 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 P <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 n m <br /> to lake, river or stream, if applicable. M Cf <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. m a <br /> PLOT PLAN <br /> I <br /> I <br /> J �N <br /> 8 N <br /> 0 <br /> a <br /> C <br /> Z <br /> souse <br /> m o c . m m 0 a F m <br /> < <br /> o� a ro 3 <br /> o m p m Z 1 <br /> F n N a <br /> M <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o 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- N m N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- o vI <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 g 0 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- d, <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 0 <br /> m 3 0 . <br /> m a A a <br /> SIGN HERE <br /> d, N <br /> (signs a owner or g contractor) (date) <br /> o : x : <br /> ZONING ADMINISTRATOR `Z g <br /> N N O N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED N P N m N O O O m <br /> 88888888m <br />