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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 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the " m <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and 3 o I n <br /> regulations of the State of Wisconsin. m V t <br /> n <br /> OWNER(Pleas Prlrlt Contrac�o Sury or or Agent o m <br /> /78 7 4DL� IV Ars <br /> Address rN�3 SG Address Ir ) <br /> City,State,Zip a N+ J 7 O City, State,Zip Code <br /> Telephone Telephone <br /> "l <br /> Emergency/Fire No. and Road Name <br /> 0 <br /> Legal Description (as Indicated on tax statement) <br /> n_ G) <br /> 0 <br /> o 'C. <br /> Permit(s) Applied for: N � <br /> Dwelling Addition Filling/Grading Camping Unit <br /> o ° <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P } <br /> Garage �1 <br /> Structure use: <br /> ase;V E <br /> (family homelcabin,garage, addition, etc.) <br /> 0 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 9 n <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). 00 <br /> 2. Show the location of the well (W),septic tank(ST),and dralnfield (DF). 3 <br /> 3. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building q Z c <br /> measurement to the ordinary high water mark of lake,stream,or river. ° I <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. C I <br /> M <br /> PLOT PLAN 111 <br /> I <br /> � 1 � <br /> 4 <br /> 301 <br /> f <br /> (od f <br /> D oc NN m �a E m <br /> D maN a . 9 <br /> Z <br /> f�7ER ) o o =r2[ a <br /> ` m <br /> 6 100 ' ( ; m c °c <br /> a <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o I m <br /> edge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all informa- N O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- 8 m g <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 <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 g o <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 AN ' <br /> SIGN HER (date) o <br /> (signature o ner r building contractor) <br /> 8 <br /> ZONING ADMINISTRATOR . . . <br /> TOWNSHIP PERMITS MAY BE REQUIRED 9 . <br /> 88888f8u <br />