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i <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 a 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> m .: d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and c <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 3 o n <br /> regulations of the State of Wisconsin. 0 m <br /> ►�)�sc�sl:, �x � m . Kt rkc4 -) a = l� <br /> OWNER (Please Print) Contractor or S rve r or Apn} o <br /> Address Addres _ <br /> City, State,Zip Code City,State, Zip Code <br /> v QP <br /> Telephone Telephone � QP <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> 0 ^ <br /> o <br /> Permit(s) Applied for: 0 <br /> '^ r <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> v 7` <br /> Z p <br /> Accessory Building Sanitary Privy Subdivision } <br /> Garage <br /> Structure Use: - o <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). O o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). on c v <br /> 3. Show dimensions infeet ofthe following:(a) building toall 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 n I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 5i <br /> dated by the owner. C <br /> PLOT PLAN m <br /> 4t,It,Al a) <br /> v <br /> l <br /> 0 <br /> O y <br /> Z <br /> 0 o .0 m <br /> 0. g am M <br /> < zNo2m3 <br /> o o <br /> F � 21 M <br /> — m <br /> 8 : € m m nt <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- g <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 m <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 O <br /> access to the above described premises at any reasonable time for the purpose of inspection. : m 83m 3 0 0 <br /> 8 : <br /> SIGN HERE ` <br /> (signature of owner or building contractor) (date) o <br /> ZONING ADMINISTRATOR I � � <br /> TOWNSHIP PERMITS MAY BE REQUIRED rn <br /> n5n , o 0. <br /> 888888 In <br />