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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator ; m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v <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 3 a <br /> regulations of the State of Wisconsin. y m <br /> m m <br /> f <br /> OWN ,Ras540 �Print) Co%racorp;Surveyor orAgent o ', <br /> AdrV,ess Add ss I <br /> -U&nLUN_ l C U shs+er. 1 <br /> City, State,Zip CoUb City, State,Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> O _ <br /> Permit(s) Applied for: o ° <br /> Dwelling Addition Filling/Grading Camping Unit g <br /> v <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage < <br /> Structure Use: <br /> (family home/cabin,garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) <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). C 3 <br /> 3. Show dimensions In feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)buildingan Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. ° n <br /> 4. It separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H <br /> dated by the owner. <br /> C i <br /> PLOT PLAN M Ul <br /> � c � l <br /> � � o <br /> N . �m <br /> m <br /> z <br /> � r <br /> �Q/� m o . � d� �, m <br /> �J� C� 3(^i Dno g. 9 n� m o N a m a <br /> 30 O <br /> z o o : m 1 <br /> P £ n _ICr In <br /> Z=- Cr m <br /> : <br /> € G) C o <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 3 i m w m <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- m N <br /> mation 1 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 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 000 <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 8 m <br /> T 3 m <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) c s <br /> ZONING ADMIN8 <br /> ISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N 8 «~ m <br /> $8 $ 8 $ $ $ 8vmi <br />