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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d / m� }'4 o <br /> APPLICATION FOR — LAND USE — PERMITS l 1 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and _ <br /> regulations of the State of Wisconsin. N m <br /> F <br /> OWNER Please Pn t) Contractor or Surveyor or Agent o m <br /> Address Address <br /> p�YtQ I S " to►� -SSBI b� <br /> City,State,Zip Code City,State,Zip Code ' <br /> l-L z- -7 <br /> Telephone Telephone ' <br /> EmerpencylFire No. and Road a e _ \ <br /> Legal Description (as Indicated on tax statement) o <br /> � v <br /> Permit(s)Applied for: 0 °- { <br /> Dwelling Addition c Filling/Grading Camping Unit 0 <br /> z o I <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: Dec 6 <br /> (family home/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). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 m <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 `o <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 <br /> dated by the owner. m <br /> C <br /> PLOT PLAN <br /> 7J <br /> I I <br /> o <br /> 15r ' <br /> m <br /> o � <br /> f <br /> I gow mm >$ g � <br /> m <br /> c' �' m a w x m a <br /> � : <br /> � , N , In <br /> m <br /> C <br /> 8 <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- g [ 0 Mm <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 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 <br /> access to the above described premises at any reasonable time for the purpose of Inspection. ` m 8 <br /> A V A 4 <br /> m : O <br /> SIGN MERE J N a i <br /> (signature of o r or building contractor) (date) <br /> o : <br /> T <br /> ZONING ADMINISTRATOR <br /> « <br /> TOWNSHIP PERMITS MAY BE REQUIRED m <br /> 88888888rma <br />