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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; m �' o <br /> APPLICATION FOR — LAND USE — PERMITS d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m 1. <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 g <br /> regulatiyns of the State of Wisconsin. H m <br /> �/�i� a f <br /> OWNEr9se Pint) Contractor or Surveyor or Agent m <br /> Addres Address <br /> �✓��. sir s�iio <br /> City,State,Zip e / City,State,Zip Code <br /> Tel one 3 Telephone <br /> Emer a /F N -56 <br /> /Pel <br /> L <br /> gal Description (as Indicated on tax statement) f <br /> n 0 <br /> Permit(s)Applied for: 0 IC <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: 1� /—�G1,/ �' r � '� <br /> (family home/cabi ,garage,additi , etc.) <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). <br /> 2. Show the location of the well (W),septic tank(ST),and dralntield (DF). 3 u <br /> 3. Show dimensions In feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building _ <br /> measurement to the ordinary high water mark of lake,stream, or river. o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and <br /> dated by the owner. 111C <br /> PLOT PLAN m �1 (� <br /> O <br /> n J JJ 0 <br /> lam'' o <br /> o <br /> ru <br /> N � <br /> Z <br /> m o c m m o n g m <br /> 33 <br /> @@. N <br /> O Y 7 T� ZI <br /> q c ,^ m <br /> ni n° O <br /> m � C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- <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 '` 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 <br /> plication.I agree to permit county officials charged with administering county ordinances or other authorized person to have ;j n <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> m i $ n a <br /> m : <br /> SIGN HERE <br /> (signature of owner or building contras orn (dat ) <br /> o : <br /> ZONING ADMINISTRATOR 8 <br /> N_ <br /> TOWNSHIP PERMITS WAY BE REQUIRED2n��N rm o o m <br /> 888888 $ 8x0 <br />