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ON CO-MPUTER/SCANNED <br /> Burnett bounty 7410 Co. Rd. IC, No. 102, Siren, WI 54872 Office of Zoning Administrator 0 o 0 <br /> APPLICA 01014 FOR - LAND USE - PERMITS3. <br /> TO THE ZONING ADMINISTRATOR:The un dersigned hereby makes application for a Permit for the work described and 5 <br /> located as shown herein. The undersigned, that all work shall be done in accordance with the requirements of the m C <br /> CD <br /> Burnett County Land Use Ordinance, Sanitati,"code, and with all other applicable County Ordinances and the laws and a U <br /> regulations of the State of Wisconsin. y v <br /> OWNER (Please Print) Contractor or Surveyor or Agent o , � <br /> Address Address <br /> City, State, Zip Coe t City, State,Zip Code ------3 <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 o <br /> 7 <br /> Dwelling Addition Filling/Grad ry Camping Unit <br /> z 0 <br /> Accessory Building Sanitary �— p,.; Subdivision <br /> Garage 4� _ <br /> Y <br /> Structure Use: <br /> r <br /> (family home - 1,arage _ -,cn, 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). i0 <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 0 0 <br /> 3. Show dimensions in feet ofthefollowing:(a) building to al'lot lines,(b)buildingto center line of road,(c)building Z <br /> measurement to the ordinary high water mark of lake,str?am, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,huilder,contractor,etc.,the plans must be signed and N <br /> dated by the owner. _� M o <br /> C i <br /> PLOT PLAN <br /> O <br /> N <br /> O <br /> 7 <br /> v � <br /> t� <br /> J <br /> Z <br /> f � <br /> o . ° -- o a f m <br /> 17 <br /> < ` <br /> Z m' 2 -1 <br /> f .p c M <br /> � o p <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c <br /> rn <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- (S d, �y, p <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 g cc 8 <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 t <br /> access to the above described premises at any reasonable time for the purpose of inspection. m g <br /> .n 3 " <br /> to <br /> SIGN HERE <br /> (signature o w r o it c tractor) (date) v ; <br /> ZONING ADMINISTRATOR ' 8 <br /> T NSHIP PERMITS MAY BE REQUIRED � o m <br /> � ���8$ 888tn <br />