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Burnett County Office of Zoning Administrator ; M f o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and a c QQ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> till of the Stfjof Wis onsm. , , <br /> w m <br /> O N R(Please Print) Contractor or Surveyor or Agent1p <br /> n f <br /> Z <br /> ��� Address <br /> City,S ,f , iI ode F(.-, City,State,Zip Code jh�! <br /> 91- <br /> Telephone Telephone <br /> VI <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition y' Moving <br /> X a <br /> Sanitary .— Camping Unit <br /> Privy Subdivision o <br /> N <br /> Structure Use: 0 <br /> (f mily hom (cabin, garage,addition,etc.) z 0 <br /> o a <br /> v <br /> m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). .� o <br /> 2. Show the location of the well (W),septic tank(ST),and drainfield(DF). <br /> 3. Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream- if within 300 ft. Q� <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, -T <br /> 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 dated by ,h <br /> the owner. <br /> n <br /> 0 <br /> 'R o <br /> Z <br /> O <br /> f <br /> 711 D <br /> 2. <br /> C <br /> -fj n <br /> t <br /> ry 1 ' <br /> N <br /> l 0 <br /> f0 6T M <br /> 0 0 <br /> N � <br /> Z <br /> O <br /> Z <br /> M QC >M = tear 0 a C m <br /> < -'m <br /> m arc 0.m ';n70 <br /> Z y; ;2wo0fo � <br /> Tn i i c i m <br /> of ` ,0»f O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are)responsible for the <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ` m m <br /> further declare that I(we)recognize that this information I (we)am(are)providing will be relied upon by the County of Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reasonable time for the purpose of inspection. '^ <br /> m <br /> SIGN HERE <br /> (sig ure of owner building contractor) (date) E o o <br /> ZONING ADMINISTRATORQ'j/ - to-n� �W9 ooNm <br /> TOWNSHIP PERMITSMAY BE REQUIRED Sa 0 U) <br />