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Burnett County Office of Zoning Administrator ; m f o <br /> APPLICATION FOR — LAND USE — PERMITS z 3 ' W <br /> 00 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and c y <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 /> fir_)S of the State of Wisconsin. � 11 m w <br /> 1\O�0.r1a -4- 13O.U,V IE lJ FPTon� �j�1'l L S/111-ry C'cXv 5'T mm J� O <br /> OWNER(Please Print) Contractor or Surveyor or Agent n n S <br /> o <br /> 191 EQTOAJ D2 m = <br /> Address Address M b <br /> FC�tOLE y vrl u 55132 (�Us'�C� �.A KE - Z <br /> City,,State,Zip Code - ` City,State,Zip Code -Il, <br /> Ta}- 5-7-1-o6s-2 (71>JQ�G yy6y ppCv <br /> Telephone Telephone a. <br /> Permits)Applied for: <br /> New Building Filling/Grading p <br /> L <br /> Addition Moving p <br /> Sanitary Camping Unit T <br /> Privy Subdivision 0 <br /> � �16L1�P o L <br /> Structure Use: v <br /> (family home/cabin,garage,addition,etc.) o 0 <br /> a <br /> m O o <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)and indicate North(N). o z, <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, <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 <br /> ( a <br /> SO <br /> ILA <br /> G) <br /> a <br /> 5 <br /> µo�SE \Il <br /> BOraT }�oJs <br /> D <br /> 0 <br /> w(vE m <br /> a <br /> 1a1, ' oN� 0 0 <br /> a3 <br /> 7J <br /> Red <br /> c.-"�""��"� I ►aty� wRT�a maRK � 'n to <br /> I ! Z <br /> I 13.0 ° <br /> �06, <br /> 0� <br /> V' <br /> ryt�z� Rgy l✓� ( ^� � !7 X <br /> A <br /> � Pf � mvNrDDmy <br /> a c �.2 m � nc <br /> m a� �'am nnS <br /> le <br /> m <br /> r) <br /> S E': c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best ofg a <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the 1'E [ m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) iF 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- ?o: <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the :a <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 /> SIGN HERE ' o E o <br /> (si ure of owner buil ' ntractor) I (date) t S [ S <br /> ZONING ADMINISTRATOR m <br /> cnwrn- oa <br /> TOWNSHIP PERMITS MAY BE REQUIREDSS SSooS(A <br />