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C- <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator (a m o 0 <br /> 2. <br /> .APPLICATION FOR — LAND USE — PERMITS <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 9 w <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 8 <br /> regulations of the State of Wisconsin. wm / <br /> Alac 4.ber�- OGL. o ��I '0 <br /> OWNER Please Print) Contractor or Surveyor ot Agent o <br /> Addri Addrest- <br /> � <br /> City, State,Zi' C6de City, State,Zip Code, <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s)Applied for: 0 <br /> Dwelling Addition Filling/Grading Camping Unit ° '} <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> Structure Use: <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 drainfleld (DF). 3 v <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building q - `v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m w' <br /> dated by the owner. C qQ <br /> PLOT PLAN m -'�— Z <br /> 4t�j' <br /> 1-11 ect— ���� rn <br /> Vi� P <br /> 5� <br /> O -1 <br /> w <br /> J <br /> i <br /> co 00 <br /> f <br /> man0 ` = a <br /> 0 coo 3 <br /> PZo m ,2 : 1 <br /> t o T y <br /> c C : m <br /> rn : Oo C <br /> 'm 2 C <br /> 1 declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- ; g m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <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 r g o 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.1 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. w 8 m <br /> B n : <br /> A r : <br /> G <br /> SIGN HERE <br /> (signature of ower or building contractor) (date) e <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> $$ 8 $ $ 888 ( <br />