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i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'oo c <br /> APPLICATION FOR — LAND USE — PERMITS <br /> m o <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 3 a <br /> regulations of the State of Wisconsin. w <br /> w m <br /> F <br /> O�W/N�ER/1Please <br /> �Print) Contractor or Surveyor or Agent o <br /> A ress ' Address <br /> ) 1� <br /> bState,Zip Code City,State,Zip Code U1 <br /> ele0one n Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> f nn <br /> Permit(s) Applied for: �- <br /> Dwelling Addition Filling/Grading Camping Unit S <br /> v <br /> p <br /> Accessory Building Sanitary Privy 0 <br /> Subdivision $ <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage,addition,etc.) on I g <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <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 dralydield (DF). 3 <br /> 3. Show dimensions In feet of thefollowing:(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. o a <br /> 4. B separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m t <br /> dated by the owner. m kl <br /> C <br /> PLOT PLAN m <br /> Nc Roo �f�� s <br /> I <br /> m <br /> A <br /> O <br /> I� <br /> O L , <br /> O � <br /> N \^r <br /> ^ IV <br /> 2 <br /> G <br /> G.�<C dw mn MO a <br /> ag � - <br /> « � 0o53mZ Q ` <br /> P <br /> c <br /> TNi a <br /> : m <br /> 3 O <br /> m c C <br /> I declare that this application(including an accompanyingschedule)has been examined b me and to the best of m knowl- <br /> edge <br /> DD (� g Y Y Y 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- !!�n » : O <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 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 O "' o <br /> access to the abov described premises at any reasonable time for the purpose of inspection. r 3 S . <br /> m o A a <br /> SIGN HERE a 0 <br /> (signature of owner o i mg co tr160 (dat ) [ o <br /> ZONING ADMINISTRATOR g . <br /> TOWNSHI PERMITS MAY BE REQUIRED 8 r««» T <br /> !'!' 8' m <br /> $ $ $ $ $ g $ $ (mn <br />