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Burnett County Office of Zoning Administrator m -V0 0 <br /> APPLICATION FOR - LAND USE - PERMITS w3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and H <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of W�consin. ti o <br /> OWN�R(Please Print) Contractor or Surveyor or Agent o <br /> m <br /> Address- „ Address Z <br /> (k:Cd':;r G i4 LL k j 1 <br /> City,State,Zip Code. City,State,Zip Code <br /> (- 7i, ) — 8'r1(s '. 3 ' I <br /> pI <br /> Telephone Telephone <br /> Permit(s)Applied for: ro <br /> New Building Filling/Grading ' <br /> Addition Moving v <br /> Sanitary — Camping Unit o <br /> Privy Subdivision m <br /> l / <br /> Structure Use: D/2//X0z� <br /> (fam'y home/cabi Z garage,addition,etc.) 0 0 <br /> a <br /> 71. <br /> _ m <br /> Directions for plot plan drawing: (1 1 <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). <br /> 2. Show the location of the well(W) septic tank(ST),and drainfield (DF). <br /> 3. Show the location of any take or flowage-if within 1000 ft.and the location of any river or stream - if within 300 ft. �-- r. <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 /> 6. Provicle legai description on the side ot thisform) as on tax statement. O <br /> PLOT PLAN <br /> a co <br /> C <br /> Z v <br /> O a <br /> `. <br /> m <br /> O <br /> 1 <br /> Z <br /> Q I <br /> e <br /> m <br /> a 0 <br /> N <br /> m <br /> 0 <br /> O <br /> ZN <br /> Z <br /> � O <br /> Z <br /> m c mmmoacam <br /> m Q< > > na= <br /> m a� =am ^ am <br /> mO M m <br /> O : : : N: M <br /> M <br /> D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o: -M <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> AC <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing y <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> m <br /> SIGN HERE /l�li.lX�nr rl .fF {A L.o <br /> (sig u of owner o ing''c//on��tracct/tor) (date) [ o E `: [ o <br /> ZONING ADMINISTRATOR <br /> 657 <br /> TOWNSHIP PERMITS MAY BE REQUIRED n u n v o o v m <br /> 0000000M <br />