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ON COMPUTER/SCANNED <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C -- o ` <br /> '- 3 <br /> APPLICATION FOR — LAND USE — PERMITS - a <br /> TO THL ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <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 a <br /> regulations of the State of Wisconsin. LO <br /> 1Z1.,A N Z— c-F - P a _ f <br /> g NF:7 (Please Pri Contractor or Surveyor or Agent m <br /> res ��n / \IL`��� Address r�C _ <br /> l'City, State, Zip ICode 1 City, State, Zip Code <br /> Telephone Telephone ; <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) <br /> CD <br /> 0 <br /> o �- <br /> Permit(s) Applied for: J <br /> 0 <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> z o <br /> Accessory Building Sanitary Privy Subdivision <br /> Garage <br /> Structure Use: -4 0 <br /> (family home/cabin, garage, addition, etc.) <br /> C N <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) i <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). 0 N <br /> 3. Show dimensions In feet of the following: (a) building to all lot lines,(b)building to center line of road,(c)building Z ocr <br /> measurement to the ordinary high water mark of lake,stream, or river. °_ a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and M N <br /> dated by the owner. <br /> PLOT PLAN m <br /> I <br /> �t rryy <br /> �1 <br /> 0 o <br /> Z <br /> Jam a �� y N <br /> O 7 J <br /> Z f0 Q' A `Z . <br /> - I <br /> N � C I <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> CD <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- d+ w w <br /> tion contained in this application(including any accompanying schedule)and I further declare that t 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 $ $ <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 <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m $ fD <br /> P - 3 A N <br /> SIGN HERE <br /> (signatu of owner or building contractor) (date) o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED r(�8 <br /> � N �� . . <br /> 8888888 <br />