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h <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned here makes m °^ <br /> g by application for a Permit for the work described and Co <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 _ n <br /> regulations of the State of Wisconsin. m <br /> to Sias a <br /> NER(PW Print) Contractor or Surveyor or Agent o m <br /> m <br /> m' <br /> r Address <br /> VJN ip C1+77, City,State,Zip Code <br /> 1 <br /> Te)epI0e� Telephone <br /> Emergency/Fire No. and Road me <br /> Legal Description (as indicated on tax statement) o <br /> c� <br /> Permits)Applied for: o <br /> 0 <br /> w r- <br /> Dwelling AddRi 'll' Grading Camping Unit o °- <br /> v <br /> Z <br /> Accessory Building _ SanitaryPri Subdivision ° <br /> Garage <br /> Structure Use: <br /> (family home/cabin, garage,addition, 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). 9 <br /> 2. Show the location of the well (yi),septic tank(ST),and dralnfield (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 o <br /> measurement to the ordinary high water mark of lake,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 y <br /> dated by the owner. o <br /> C <br /> PLOT PLAN m <br /> l <br /> 614 <br /> �i o <br /> 0 <br /> � L <br /> m n <br /> w <br /> r <br /> G7 � <br /> f <br /> mo � � mm �aV m <br /> < zS' Z H o o m 3 <br /> zo m ,Z <br /> 0 _ a <br /> c ' C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation 1 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 inthis ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premises at any reasonable time for the purpose of inspection. m 3 g <br /> B � Ax : <br /> N N <br /> � N <br /> SIGN HERE <br /> (signature of owner or building contractor) �-7�� '! (date) c s <br /> ZONING ADMINISTRATOR �(L er f - . 8 <br /> TOWNSHIP PERMITS MAY B REQUIRED N N N <br /> oo8 m <br /> gggrmn <br />