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of 1 r <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratord m 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 c <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m 0 <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 a r �{ <br /> regulations of the State of Wi onsin. n N m V ' <br /> ac <br /> caaQ <br /> OWNER P ase Print) Contractor or Surveyor or Agent o <br /> Address Address <br /> u)ebs&P . A)-T— E-Ik t3 fes, i 0/g7a _ <br /> City,State,Zip Code City,State, Zip Code o <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> n � <br /> Permit(s) Applied for: 0 �- <br /> Dwelling Addition Filling/Grading Camping Unit B o <br /> v <br /> 0 o <br /> Accessory Building Sanitary Privy Subdivision p m <br /> Garage <br /> Structure Use: <br /> 0 <br /> (family home/cabin,garage, addition, etc.) <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). o <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show dimensions in feet of thefollowing:(a) buildingto all lot lines,(b)buildingto center line of road,(c)building O z a <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 T. <br /> S <br /> dated by the owner. C <br /> PLOT PLAN m L <br /> 0 <br /> 5 <br /> X07 <br /> o <br /> ICI <br /> N <br /> O- <br /> J Z <br /> 7J <br /> o c an d a F m <br /> T- M <br /> o F 5 T' <br /> = m € m <br /> u m c C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knows- <br /> 8 ` Am : 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- w m H O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 0 N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ m g <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 u, o <br /> access to the above described premises at any reasonable time for the purpose of inspection. $ m <br /> m V A m <br /> m m <br /> N H <br /> SIGN HERE `= n <br /> (signature of owner or building contractor) (date) o x, <br /> $ <br /> ZONING ADMINISTRATOR ' <br /> a <br /> TOWNSHIP PERMITS MAY BE REOUIRED & o 8 8 m <br /> 88 $ $ 8888rmn <br />