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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS z 3 ° <br /> TO (HE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 <br /> t1094 of the State of Wisconsin. o �- <br /> OW ERPI ase�Nnt) Contractor or Surveyor or Agent <br /> A drgrWb 7-, <br /> Address � W <br /> City,State,Zip Code City,State,Zip Code <br /> OC <br /> Telephone Telephone <br /> k <br /> Emergency/Fire No. and Road Name <br /> Legal Description(as indicated on tax statement) <br /> Permits)Applied for: 0 <br /> o <br /> New Building Sanitary FillinglGrading Camping Unit m <br /> Addition Privy Moving Subdivision o <br /> o <br /> Structure Use: el )- � .8 ° <br /> (family homelcabin, garage,type of addition, etc.) <br /> r <br /> Directions for plot plan drawing: <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 drainfield (DF). 0 <br /> 3.Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream - if within 300 ft. <br /> 4.Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to ordi- <br /> nary high water mark of lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. O <br /> 0 <br /> 3 <br /> PLOT PLAN o m <br /> Z c <br /> 0 a <br /> a <br /> N. <br /> t � <br /> � co <br /> N <br /> v > <br /> J <br /> o <br /> °. so <br /> Imo, <br /> 0 <br /> V✓ � <br /> 1 Z <br /> D <br /> G <br /> M coM Nr DD toy <br /> m c .0 m n a c <br /> n o< JJna- m <br /> N � N O J� <br /> 2 <br /> Z O <br /> Oo cn <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <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 ' a <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> q m <br /> SIGN HERE <br /> (s' n ture of ownepjr building contractor) (date) <br /> ZONING ADMINISTRATOR o o <br /> -n <br /> JNO V <br /> TOWNSHIP PERMIT MAY BE REQUIRED o00o fmA <br /> I <br />