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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administratorm m o 0 <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 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the N C <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;#Wisconsin. m iA <br /> �p �{tj I <br /> OWE(Please Prt) L� Contractor or Surveyor or Agent m m <br /> m <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code <br /> 6 /<a — yea - 3757 <br /> Telephone Telephone <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as Indicated on tax statement) <br /> o <br /> Permit(s)Applied for: �- <br /> a ,- <br /> Dwelling Addition Filling/Grading Camping Unit ° g <br /> v <br /> Z 'o <br /> Accessory Building Sanitary Privy Subdivision o } <br /> Garage <br /> Structure Use: °hr'— MLA <br /> ) y L-KJ o <br /> (family home/cabin,garage, addition,etc.) in f <br /> O <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and indicate North (N). O a <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield (DF). 3 v, <br /> 3. Show dimensions In feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building 0 c <br /> measurement to the ordinary high water mark of lake,stream,or river. 0 n <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m o <br /> dated by the owner. C I 0 <br /> L)4 <br /> m = <br /> PLOT PLAN T <br /> J I G If co <br /> Ste LVC,� <br /> m <br /> I <br /> Z <br /> o c m m n E m <br /> � Dii� mnNa = a <br /> m <br /> o f M <br /> = = In <br /> CD <br /> I declare that this application(Including any accompanying schedule)has been examined by me and to the best of my knowl- <br /> g ` Wim ' a <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- .w m O <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- i$m ut <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I $ m $ <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this - y! <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have m '.J' a <br /> i 0 <br /> access to the above described premises at any reasonable time for the purpose of inspection. 8 <br /> A a <br /> m : a 8 <br /> .` o 8 : <br /> SIGN HERE /.'rF ';' " . <br /> a : <br /> (signature of o ner r ad'n t To(date) c s <br /> ZONING ADMINISTRATOR <br /> TOW HIP PERMITS MAY BE REQUIRED <br /> un fin . <br /> 88888888v <br />