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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d 'o - 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> '- 3 <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and m <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 <br /> regulation of the State of Wisconsin. y G Y1 J <br /> O NER (Please Print) Contractor or Surveyor or Agent o <br /> m <br /> Adyc�ss L y 1� <br /> Vt iti��S VC'r"1�- Ll.� .l Stf `f 3 AdC��rc ro <br /> City, State, Zip Cod �{ City,State,Zip Code n <br /> Telephone Telephone <br /> 1 <br /> 2.�. <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) o <br /> 51 <br /> o <br /> Permit(s)Applied for: ? 4 <br /> m Or <br /> Dwelling Addition Filling/Grading Camping Unit o 7� <br /> v !n` <br /> Z a r <br /> Accessory Building Sanitary Privy Subdivision ° m <br /> Garage <br /> Structure Use: }/J�I �Cl I�eel-1i- ua <br /> (family home/cabin, garage, additio , 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). <br /> 2. Show the location of the well (W),septic tank (ST), and drainfield (DF). 3 <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream- if within o m <br /> 300 ft. <br /> o n <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building 5 <br /> N. <br /> to lake, river or stream, if applicable. m �) <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. fA r�y <br /> PLOT PLAN <br /> tia <br /> 0 <br /> Z 4�1 <br /> 1 <br /> Z <br /> I N D <br /> f <br /> D lnmv (nr DDp <br /> o c . mm - o. F m <br /> a < ,� N <br /> 00 00 <br /> P <br /> g 32 <br /> C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- c ' m ' m <br /> 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- y! p <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 i 8 m 8 <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 c, <br /> access to the above described premises at any reasonable time for the purpose of inspection. [ m 8 o E <br /> m V A N <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) ; <br /> o : x : <br /> ZONING ADMINISTRATOR <br /> \ r d1N(A <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N 0 ' T o o m <br /> 8E�888N <br />