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n2 Pmgj1 <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d M 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the '° m C\ <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. _ ( y m_ <br /> OAy. d F � C t, k,L_ A _- d A LF M £ <br /> OWNER (Please Print) Contractor or Surveyor or Agent m <br /> Address Address <br /> City, State,Zip Code City, State,Zip Code <br /> -7i5-- SY4, (�— '/l G. C <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name r) <br /> Legal Description (as indicated on tax statement) <br /> o <br /> Permit(s) Applied for: <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit Qj <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision o <br /> Garage <br /> Structure Use: — I - I(�,Jl <br /> 0 <br /> (family home/cabin, garage, add'ion, etc.) Mill <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <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). 0 a3 v <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)bulldingto center line of road,(c)building R Z c <br /> measurement to the ordinary high water mark of lake,stream, or river. C <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and in <br /> S <br /> dated by the owner. C <br /> PLOT PLAN (A W <br /> m <br /> 0 <br /> N <br /> o <br /> N <br /> ~ I� <br /> Z <br /> V <br /> IIIIGI�-` <br /> M o c m d > > y m <br /> m - a� '; nm <br /> P fes : ;ITz : � <br /> m <br /> ) » o <br /> g <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- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation 1 am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m g <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 reason le time for the purpose of inspection. $ 0 <br /> N <br /> SIGN HERE <br /> (signature of o r i ntracton `(d e) <br /> ZONING ADMINISTRATOR /✓ <br /> TOWNSHIP PERMITS MAY BE REQUIRED 199 " «« 9 m <br /> N N N O O . <br />