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(iC'l7YYZI(� <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator Cn 'M, o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> s <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and Zm <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 C Jtn <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and (Jl <br /> regulations of the State of Wisconsin. H m <br /> c m <br /> rL,4nf -1 h"?5 11 <br /> OWNER (Plea Pri t) Con <br /> y�ctororSurveyor nrAgent o <br /> Hui P . Vic, + '�r7 1�-)V <br /> Aqpress Addr ss� <br /> City, State, Zip Code City, State, Zip Code <br /> �S�— <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> L7 <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 0 <br /> Garage <br /> Structure Use: r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 9 0 <br /> 2. Show the location of the well (W),septic tank (ST),and drainfield (DF). C 3 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within P C <br /> 300 ft. o i <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building my <br /> to lake, river or stream, if applicable. m <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C <br /> dated by the owner. 1 <br /> m w <br /> PLOT PLAN <br /> o R� <br /> N <br /> V13F <br /> r � <br /> N_ <br /> ` Z-- <br /> I <br /> m o C 0 w n a m <br /> m <br /> A. D <br /> P 0i TNi a <br /> L" I ii M <br /> g ate =. c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c '� i m <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 g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 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 /> 00 o <br /> inspection.access to the above described premises at any reasonable time for the purpose of : 3 8 <br /> m 3 ° <br /> m v � in [ <br /> m m as <br /> H N 8 <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) ' <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED ,'o -n <br /> $ 8888888ai <br />