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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3, <br /> m 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v H <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 3 0 <br /> regulations of the State of Wisconsin. m <br /> ��f?��✓l G �i L.D, /°a f/coi^l a E <br /> OWNER (Please Print) Contractor or Surveyor or Agent m <br /> 903,- .�7,p m <br /> Address Address <br /> ?S <br /> City, State, Zipp Code City, State, Zip Code <br /> I �b <br /> C,// W l 7/S <br /> Telephone Telephone <br /> e & & -73FO <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: 0 �- <br /> w r <br /> Dwelling Addition Filling/Grading Camping Unit ° g <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision va <br /> ° - <br /> Garage <br /> Structure Use: <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <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). O <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). 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 In <br /> ? T <br /> 300 ft. o n <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 <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 w ` <br /> dated by the owner. ftl S <br /> PLOT PLAN <br /> l <br /> Se 41cta00y <br /> 0 <br /> o <br /> w <br /> Z <br /> I <br /> mo c M. m m o a g m <br /> �. a00 aA M <br /> C .v m - 3 <br /> Z 0 00 _042 <br /> 7 m <br /> ? f 2i M <br /> An L O <br /> g <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 <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- 'm <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- <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. <br /> T n <br /> SIGN HERE <br /> (signatur owner uild)ing contrac (date) <br /> ZONING ADMINISTRATOR c x <br /> a E 8 <br /> (q(qH <br /> TOWNSHIP PERMITS MAY BE REQUIRED -nN N N n n v8 vN8 8 o om <br /> $ $ 8 $ $ 8 . , mn <br />