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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator0 1 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of theStateof Wisconsin. <br /> OWN (Please Print) Contractor or Surveyor or Agent o <br /> Address ,. p -/i N(l} Address <br /> City, State, Zip Code City,State, Zip Code r <br /> Telephone Telephone <br /> ?-u ?ol 6s3-.?ZIP <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: o <br /> N r <br /> Dwelling Addition Filling/Grading Camping Unit °^ <br /> v <br /> z o <br /> Accessory BuiltlingSanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <br /> (fami ome/cabin, garage,addition, 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). o <br /> 2. Show the location of the well (W),septic tank (ST),and dreinfield (DF). 0 3 <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 v <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m y <br /> dated by the owner. <br /> C t <br /> PLOT PLAN �r- ,-�«,....,,-._.t ,1 r'hv M - <br /> N <br /> M td W <br /> O. <br /> 0 <br /> r <br /> ft <br /> z <br /> S t � <br /> ------------- <br /> w <br /> I <br /> M O C m m 0 6 <br /> ary M <br /> v < ! : `Z N O J J 3 <br /> P f 7 : : a Q " <br /> m <br /> N i D <br /> 8 € C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o : 0 <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- q!� G): <br /> O <br /> tion contained in this application(including any accompanying schedule)and I further declare that 1 recognize that this infor- S m u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 m 8 <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 t7 <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 80 <br /> n 3AH <br /> N N <br /> SIGN HERE <br /> II (signal4r0of olmner or building co ac 4 r —Irf <br /> u - V <br /> ZONING ADMINISTRATOR __—_ <br /> w" <br /> TOWNSHIP PERMI MAY BE REQUIRED <br /> 8 888888ai <br /> L� <br /> i <br />