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Bum itt County 7410.Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> m a <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 2 c <br /> OQ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 3 <br /> Burnett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and <br /> re lationsofth State ofWiscons�i <br /> f <br /> OW R lease P 'nt) Contractor or Surveyor or Agent ° <br /> Rj <br /> Add\ � )e� I� SWO11 Address Jj <br /> City,St ,Zip Code City,State,Zip Cade Qj <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> Permit(s) Applied for: o °- <br /> _ <br /> Dwelling Addition Filling/Grading Camping Unit °— <br /> z a <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage ' <br /> Structure Use: <br /> � r 'I`/ I"fr l�^�1 00lA (>O o <br /> (family home/ in,garage, dition, etc.) OQ <br /> 1A <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). <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 3 v <br /> 3. Show dimensions in feet of thefollowing:(a)building to all lot lines,(b)building to center line of road,(c)building 91 <br /> 91 z `v <br /> measurement to the ordinary high water mark of lake,stream,or river. o o <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m H: ICI <br /> dated by the owner. <br /> C <br /> PLOT PLAN m <br /> l <br /> N <br /> m <br /> n <br /> _ <br /> O <br /> m <br /> ° y <br /> N <br /> I <br /> i <br /> G <br /> A o c 2 m m $ n F m <br /> mD <br /> Pa 4a C `D C <br /> P o [ o � i <br /> ° _ : N m <br /> i B [ O <br /> 8 2 : <br /> 1 declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- o m A 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- « 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. 1 8 m g <br /> further accept all liability which may be a result of the County of Burnett relying on this information 1 am providing in this 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. ro g m <br /> m 3 ^ <br /> SIGN HERE d' a <br /> (signature of owner or building contractor) (date) o ' s <br /> ZONING ADMINISTRATOR \ / 4 <br /> «_ <br /> TOWNSHIP PERMITS MAY BE REQUIRED o To«S' An <br /> $ 8 $ 888 ( <br />