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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m a o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m 02 <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> requisitions of the State of isconsin. <br /> N 0 <br /> n O <br /> OWNERPlease Print �— <br /> ( ) Contractor or Surveyor or Agent <br /> h o <br /> �r�,Cu Lho /�� <br /> Address Address <br /> F—�z dS�ril IA) 54--0((o <br /> CitySt/!< Core V 9/ Cry, State,Zip CodeTelephones + (O Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Q <br /> Permit(s)Applied for: o <br /> r <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: 5 <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). a <br /> 2. Show the location of the well (W),septic tank(ST),and dralnfield (DF). 3 <br /> 3. Show dimensions Infest ofthefollowing:(a) building to all lot lines,(b)building to center line of road,(c)building Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. o a <br /> 4. H separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and mH <br /> dated by the owner. <br /> C <br /> PLOT PLAN w <br /> 111 <br /> 7:R -ea) aC of <br /> Po <br /> N <br /> O <br /> J <br /> m <br /> O y <br /> m <br /> Z <br /> f <br /> n o <br /> am a m M <br /> O < :5 `Z o O J m ; <br /> 2 R p <br /> £ = ' m o : m <br /> M <br /> I declare that this application(includ' ny accompanying schedule)has been examined by me and to the best of my knowl- 5' : <br /> M <br /> edge and belief it Is true,c ect a complete.I acknowledge that I am responsible for the detail and accuracy of all informs- — N m O <br /> tion contained in this ap i anon( cluding any accompanying schedule)and I further declare that I recognize that this infor. <br /> Mallon I am providing i be veli upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g m g <br /> further accept all Ilabil which may e a result of the County of Burnett relying on this information I am providing in this ap- �, <br /> plication.I agree to it county offic s charged wi h administering county ordinances or other auth rued p on to have �, <br /> access to the above ribed Dr mixes n re able time for the purpose of inspection. m g mo <br /> T 3 n <br /> m vypm <br /> N N O <br /> SIGN HERE <br /> ignature of owner or building contractor) (date) s <br /> e : o : <br /> ZONING AD ISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED to 82 o to 08 m <br /> 88888 $$ $ rmn <br />