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Burnett 0ounty Office of Zoning Administrator ; m o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> e <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <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 /> ti ns of the State of WI Go <br /> J U� � m <br /> OWNER(Please Print Contractor <br /> _�( ' I or S rveyor or gent <br /> 'o n f <br /> �q A <br /> Addrs Addres g, <br /> I4F'PT�Pt', VILZ —`SUR bL�h�#�f <br /> City,State,zip Code City,State,Zip Code „1 <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> N � <br /> Structure Use: ° <br /> (family hometcabin,garage,addition,etc.) Z <br /> 9 0 o <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. <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, 0 o <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 <br /> the owner. <br /> ° a� <br /> a r <br /> 4- <br /> V0 <br /> - <br /> B c a <br /> n <br /> y <br /> O <br /> _ <br /> 71 <br /> N <br /> O <br /> J N <br /> m <br /> O p' <br /> w 'J <br /> t Y <br /> (Qj <br /> O <br /> Z <br /> a <br /> f <br /> Nc W N n 2 C� <br /> ° v< MJmo.-.m <br /> aam <br /> <' -co <br /> m Z m 0 =m <br /> Z 05,33 <br /> of <br /> N: M <br /> o c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of g <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for the i i m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <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 :p <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- c <br /> mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (si ature of owner or building contractor) (date) <br /> -N b <br /> o: o <br /> ZONING ADMINISTRATOR ` '• ` ` ` w� <br /> VNO V <br /> TI NN(TN 00(Tm <br /> TOWNSHIP PERMITS MAY BE REQUIRED SS SSSSSy <br />