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.. r.. r <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'a o / a <br /> -APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and <br /> ffi <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the v c <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. <br /> N 01 <br /> "\r Fp �t� zeRc, <br /> f <br /> NER ase n Contractor or Surveyor or Agent olux III <br /> Address <br /> Ci tate,Zip Code D I City, State,Zip Code <br /> - 3 2"7- R� <br /> Telephone Telephoner (\1 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) o <br /> n 0 <br /> Permit(s) Applied for: o ° J <br /> o -- <br /> �^ r J <br /> Dwelling ditien---_� Filling/Grading Camping Unit 6 <br /> \ v <br /> Accessory Building Sanitary Subdivision ° $ <br /> arage <br /> Structure Use: a r <br /> (family home/cabin, garage,addition, etc.) <br /> 11 <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) C <br /> A <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). <br /> 2. Show the location of the well (W),septic tank (ST),and draiMield (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 z e <br /> measurement to the ordinary high water mark of take,stream,or river. o 0 <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and 5 -`— <br /> dated by the owner. M <br /> PLOT PLAN m �, <br /> I <br /> N <br /> 0 <br /> w <br /> Z <br /> S <br /> f <br /> Moc o m .> a E m <br /> Z o € �O0 <br /> f <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o L 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. 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. 1 g 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- y! <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have n Ji o <br /> access to the above described pre ises at any reasonable time for the purpose of inspection. v 8 S <br /> m 3 A m <br /> SIGN HERE <br /> (si nature of owner or ildi contr (date) <br /> ZONING ADMINISTRATOR g <br /> N <br /> TOWN IP PERMITS MAY BE REQUIREDS o o 9 m <br /> 8 888rmn <br />