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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; m o 0 <br /> E <br /> APPLICATION FOR — LAND USE — PERMITS d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and N <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 i,tonin. <br /> o , a <br /> OWNER (Please Pri Contractor or Surveyor or Agent o <br /> aZU <br /> IV <br /> Address _ p Address <br /> .SD . sr • �CLGIr � M& 55a7-5 Ir <br /> City,State,Zip Code City, State, Zip Code <br /> 5 5 - !0 hl <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o o <br /> Permit(s)Applied for: 0 'C. <br /> '^ r <br /> ;ccessory <br /> welli � Addition Filling/Grading Camping Unit S » <br /> v <br /> Z o <br /> Building Sanitary Privy Subdivision o } <br /> Garage <br /> Structure Use� S'" o <br /> (family h6melcabin, garage, addition,etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) X W <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O o <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). v3 u <br /> 3. Show dimensions In feet of the following:(a)bulldingto all lot lines,(b)building to center line of road,(c)building 1A ' o <br /> measurement to the ordinary high water mark of lake,stream,or river. o n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. C <br /> PLOT PLAN 6, wQ ' m <br /> O <br /> Z <br /> 11CA <br /> 0 <br /> N <br /> _ <br /> , rn <br /> rpN � (Ar DD O MM <br /> M <br /> U) <br /> — � , : m <br /> U ii G) O <br /> 8 ae : C <br /> declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c m A: 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 G): <br /> O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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.1 agree to permit county officials charged with administering county ordinances or other authorized person to have N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 <br /> N A m <br /> m A <br /> rl M N O <br /> SIGN HERE C Q <br /> (signatu�f owner or budding contractor) (date) o <br /> ZONING ADMINISTRATOR JI " <br /> TOWNSHIP i R)T Mr ITS MAY BE REQUIREDi 8IGg ' <br /> , o m <br /> 8888 8rmn <br />