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Burnett County.7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS — <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and v w <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 0 <br /> regulations of the State of Wisconsin. N m_ <br /> rDU1JAW co N o`� t �`_ a f <br /> W R (Pte a Pri Contractor or Surveyor or Ag m <br /> �'�I_ m <br /> Z�VVt`."1 Address <br /> City, State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> i <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) IQ <br /> Permit(s)Applied for: 0 0 <br /> `- <br /> Dwelling AdOWilling/Grading Camping Unit <br /> T <br /> z o <br /> Accessory Building Santary Pri Subdivision ° m <br /> Garage ®r,-Structure Use: <br /> (familyhome/cabin, garage,addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) 2 <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 t— u <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 <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 <br /> dated by the owner. C Y O <br /> PLOT PLAN 0 <br /> y <br /> 1 <br /> o <br /> O � <br /> N <br /> Z <br /> r <br /> D o c ro m $ a g m <br /> m. aa'� anN a = a <br /> e a < 01 C <br /> o f 0i <br /> ZZ [ m <br /> amom : c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- 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- �'c yy!! It O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this intor- 75 m N <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I g e $ <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 O o <br /> access to the above described premises at any reasonable time for the purpose of inspection. 1 8 s <br /> M to O N <br /> SIGN HERE H n <br /> (signature of owner or building eo racto (date) c s : <br /> ZONING ADMINISTRATOR <br /> M M N N N T <br /> TOWNSHIP PER ITS MAY BE REOUIRED N N 0 0 n <br /> $ '9 9;9 <br />