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Burnett County 7410 Co. Rd. K, #102, Siren, MI 54872 Office of Zoning Administrator jF o <br /> APPLICATION FOR - LAND USE - PERMITS - 3. <br /> w o <br /> TO Tt4-c 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 Bur- m c N <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. p <br /> m d <br /> T N <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> m <br /> T <br /> Address _ Address <br /> G-1 30 <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone ) <br /> Permit(s)Applied for: rl <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n o <br /> Privy Subdivision w *C.. <br /> Structure Use: 0 <br /> (family home/cabin, garage,addition,etc.) o v0 <br /> m <br /> Directions for plot plan drawing: <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 drainfield(DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft.and the location of any river or stream-if within 300 ft. <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 6 Provide legal land description n <br /> 0 <br /> PLOT PLAN 1 <br /> Z a <br /> o n <br /> o <br /> J <br /> k1 <br /> o <br /> 0 <br /> 0 <br /> N � <br /> n <br /> Z <br /> m <br /> Z <br /> O <br /> Z <br /> rnvmr DDOo� <br /> n <br /> m <br /> o < °1W0Mn <br /> O ] : <br /> o) M <br /> «3: m <br /> g ' C) <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m o C <br /> PP (� 9 Y ) Y ll <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that y o p <br /> PP ( 9 Y ) 9 <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing a <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorizedLY <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (signal of owner or bui 'ng contractor) (date) ' <br /> (j o; o <br /> ZONING AD ISTRATOR 1` ` o <br /> WNSHIP PERMITS MAY E REQUIRED ((Pic)�N N� <br /> �/o 0000' <br /> 00000 <br />