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i <br /> Burnett Cormty 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator T o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3' <br /> d o <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and H U <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 n <br /> regulations of the State of Wisconsin. <br /> o <br /> /�1,& ��1/ i �/�5/l.Li a <br /> f <br /> OWNF,A PI�Se Print} Contractor or Surveyor or Agent o <br /> Address / d /1 � • Address <br /> City, State,Zip Code Lit- o� City, State, Zip Code l <br /> TelephoneTelephone (0 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) 1 <br /> o CA <br /> Permit(s) Applied for: 0 n <br /> w r <br /> Dwelling Addition Filling/Grading Camping Unit <br /> Z o �! <br /> Accessory Building Sanitary y Privy Subdivision ° ) <br /> Garage <br /> Structure Use: — r <br /> (family home/cab' , garage, ad on, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: C <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). 9 0 <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 <br /> 300 ft. o a <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building m m <br /> to lake, river or stream, if applicable. <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. m W S <br /> PLOT PLAN <br /> I <br /> n <br /> G o <br /> fn' <br /> l � <br /> Z <br /> l z <br /> 1 /�] I- ld C V (n V <br /> tU C_ Qry ,�f (S:S if,'PL'1 1�, 1-��p�� 94 To t_Q ff2l S 5/C 1+�. -� ° a� 0 M <br /> 900 .0 rp <br /> P ( 7 Z mp <br /> Wo4lc' 14, L" � /"au''e� /. � F o : _ m : m <br /> wew c�r.T-6L c <br /> g : a , <br /> I declare that this application(including any Lcom;parlying schedule)has been examined by me and to the best of my knowl- o m 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- rn m Fw 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 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 ct N o <br /> access to the above described premises at any reasonable time for the purpose of inspection. <br /> m i 3 n <br /> SIGN HERE <br /> (sign 5109 of owner o b Iding contractor) (date) o x <br /> ZONING ADMINISTRATOR 8 <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o 9 m <br /> 8 898N <br />