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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d m O o <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 'z m '^ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 0 <br /> reguI tions of the State of Wisconsin. _ <br /> 0 <br /> OWNER (Please Pri t) / y Contractor or Surveyor or Agent o <br /> d,„e ; Address = ' <br /> City, State,Z1 Code 7 V City, State, Zip Code <br /> Telephone Telephone <br /> Emergency/Fire No. %R <br /> oatl Name �p <br /> L A y 12PSrL.if' <br /> Legal Description (as Indicated on tax statement) o <br /> Permit(s) Applied for: o <br /> o < <br /> Dwelling Addition Filling/Grading Camping Unit o <br /> Accessory Building _ Sanita Z <br /> Garage <br /> Sanitary Pnvy Subdivision ° <br /> Structure Use: $� L��JGl� /g�cli <br /> (family home/cabin, garage, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: 0 <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). X 0 <br /> 2. Show the location of the well (W),septic tank (ST), and dralnfield (DF). 0 0 <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- If within 3 rn <br /> 300 ft. Z 0 <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 0 <br /> to lake, river or stream, if applicable. m o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C ' <br /> dated by the owner. <br /> m <br /> PLOT PLAN <br /> 6a r-age- 40 be--� <br /> l� y <br /> n <br /> no Gcza�,�. <br /> -f-- `4o <br /> m <br /> \ to N -ornr D n7 <br /> a <br /> � fo i���✓� / FSE E - E D <br /> $ c <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- S E <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- d, m <br /> m O <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 8 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 c officials charged w' roistering county ordinances or other authorized person to have ro <br /> access to the above ri remise at any r onab time ose of inspection. O v, O f <br /> T <br /> 3 A 1 : <br /> SIGN HERE Z " ' `'" 8: ' <br /> j <br /> signature of w a or ding c ntractor) (dale) � <br /> ZONING ADMINISTRATOR `/L'Yl i�RYli01�7•-/I 8 E p <br /> TOWNSHIP PERMITS MAY BE REQUIREDnEn nH 8 n w w r <br /> N U t {l i N N o o O m <br /> 8888888 $ x, <br />