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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator � o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- i <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n ` � <br /> tions of the State of Wisconsin. OT <br /> w <br /> OWNE (Please Print) Contra for or urveyor or Agent o- f <br /> Address Addres <br /> i�c. nlS 9 i 3 li t W <br /> City, State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> Permit(s)Applied for: o <br /> New Building Sanitary Filling/Grading Camping Unit 3 <br /> N <br /> Addition Privy Moving Subdivision g <br /> v <br /> Structure Use: 0 0 <br /> (family homelcabin, garage, type of addition,etc.) m <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). . <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. '°r <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. n <br /> 0 <br /> 3 <br /> PLOT PLAN a m <br /> Z <br /> O O <br /> n <br /> y <br /> I 0 <br /> J <br /> nyl� s <br /> i <br /> e <br /> J <br /> P�rouecr��c)I �� �o� (� ^ <br /> 00V tS pot app,�,a "t&U^�s <br /> ( Z <br /> D <br /> 0 c M.W N 0 a a m <br /> O Q< J n O n-• m <br /> m <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- m <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 /> T <br /> N <br /> SIGN HERE . . `: <br /> (signature of owner or building contrac or) (date) <br /> o o <br /> ZONING ADMINISTRATOR <br /> w -n <br /> NNON �Nm <br /> TOWNSHIP PERMITS MAY BE REQUIRED Pum <br />