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Burnett 0;+unty,7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3, ' — <br /> m o <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 m <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. w m <br /> iS01 c 3�D�� S�( F <br /> WN R P rimhContractor or Surveyor or Agent 'a m <br /> Add r Address <br /> City, State,Zip Codki City, State,Zip Code <br /> Telephone Telephone <br /> C1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> m <br /> Permit(s)Applied for: J <br /> m r <br /> Dwelling Ad Iling/Grading Camping Unit ° °^ <br /> Z o <br /> Accessory Building Sanitaryvy Subdivision ° $ <br /> Garage <br /> Structure Use: o <br /> (family home/cabin,garage,addition, etc.) <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings(NB) and Indicate North (N). 2 <br /> 2. Show the location of the well (W),septic tank(ST),and drainfleld (DF). 3 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 91 z v <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 m H llll(C_ <br /> dated by the owner. C ° <br /> PLOT PLAN m W <br /> Cl- <br /> If <br /> J <br /> a I�. <br /> 1 � <br /> ^' I <br /> l � <br /> = < � Zwom3 <br /> oZ m ci WQ : <br /> T <br /> f J i C ? i r <br /> m c i C <br /> 8 m m r <br /> declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> Iinforms- <br /> edge <br /> : e , r <br /> edge and belief it is true,correct and complete.1 acknowledge that I am responsible for the detail and accuracy of all informs- c ' y! m t <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- : 25 m u, <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <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 g <br /> access to the above described premises t any reasonable time for the purpose of inspection. ' PH :g <br /> A 4 <br /> SIGN HERE a a <br /> (signattille of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED 00 <br /> 888 888 <br />