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Burnett County Office of Zoning Administrator f o <br /> APPLICATION FOR — LAND USE — PERMITS d 3_ <br /> z s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> tions o the State of Wisconsin. - <br /> � <br /> Jr <br /> m <br /> OWNER lease Printi -� Contractor or Surveyor or Agent n f <br /> r a <br /> w � <br /> Add e s Address <br /> Mr g, <br /> //rai, AnAl 55037 I C71C <br /> City,Ste,Zip C de City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: M ' <br /> New Building ✓ Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> _ <br /> N -y <br /> Structure Use: (7016h 3010 1 1139M <br /> (family home/cabin, garage,addition,etc.) z <br /> P <br /> a <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). 4- (� <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. o <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, <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 /> o 1 <br /> 3 <br /> v <br /> 0?0 <br /> z <br /> 0 <br /> 0 <br /> m � <br /> 0 0 <br /> w = <br /> o <br /> 2 <br /> z <br /> n <br /> JJfn�rnr D Deny <br /> m n� nm �n7o <br /> Z m <br /> fop = 0 <br /> o a t Z 1 <br /> ^' € m <br /> Cc E O <br /> �o? 2 C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(oud knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are) responsible for the '�=: E '. m <br /> detail $nd accuracy of all information contained in this application (including any accompanying schedule) and I (we) O <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 informatio I(we)am(are)providing in this application. I(we)agree to permit county offi- <br /> cials charged with administering county finance othe thorized person to have access to the above described pre- <br /> mises at any reasonable time for t p e of ' pec ' n <br /> m <br /> SIGN HERE <br /> (stg y'7 Gor bu' g contractor) (date) o i o <br /> lc' Ul <br /> o: o <br /> ZONING ADMINIST. TOR - (� <br /> �{ N UOi O to <br /> TOWNSHIP PERMITS MAY BE REQUIRED v o 8 0 0 <br />