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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 a c <br /> APPLICATION FOR — LAND USE — PERMITS 3' 1E <br /> iu o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and ? 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 <br /> regulations of the State of Wisconsin. H m <br /> OWNER (Please Print) Contractor or Surveyor or Agent o <br /> Address Address <br /> �Sy� r �. Y C.7l <br /> ry/�pCo' t.— <br /> City,State, Zip Code City, State,Zip Code <br /> Telephone Telephone T <br /> i <br /> Sl <br /> Emergency/Fire No. and Road Name 9,9-'9 fa,1VAi LK <br /> Legal Description (as Indicated on tax statement) I �f <br /> 0 <br /> — o <br /> Permit(s) Applied for: 0 �- <br /> w r <br /> Dwelling Addition Filling/Grading Camping Unit S g <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision P <br /> Garage <br /> Structure Use: ti 0 <br /> (family home/cabin, garage,addition, etc.) 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) I <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 0 0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 11 `03 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 <br /> measurement to the ordinary high water mark of lake,stream, or river. C a I/ <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m <br /> dated by the owner. C V' 0 ` <br /> I <br /> PLOT PLAN m S <br /> n <br /> 1 N <br /> 0 <br /> N <br /> 0 <br /> v � <br /> N IN <br /> z <br /> O c m w o n m <br /> m - a� � aA afD a <br /> 0 L m o . $ <br /> o f �0 r� i <br /> _ Er : m <br /> N m C C_ <br /> 8 Nm 1 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- m <br /> 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- w m O <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 m N o <br /> access to the above describ premso b <br /> ises at any reale time for the purpose of inspection. $ <br /> m 3 <br /> W A N <br /> SIGN HERE ` a <br /> (signature of owner uil i cc <br /> ZONING ADMINISTRATOR <br /> 1 �{j, <br /> TOWNS IP PERMITS MAY BE REQUIRED u�(� u N N _ .8 8 8 m <br /> 8188 89 $ m <br />