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�-y � Cl ✓y ) �d <br /> Burnett County Office of Zoning Administrator m 'D o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Z m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a 1 <br /> tions of the State of Wisconsin.Lou 0p <br /> N d <br /> N <br /> OWNER( rJ(Please t f Print Contractor or Surveyor or Agent o � <br /> 9/� <br /> m <br /> Ad ress Address <br /> /rLL..klA tk.lZ 1vK% s SC i.Z (�pJ <br /> City,State,Zip Code City, State,Zip Code <br /> Z - i12y - Gk7`I <br /> Telephone Telephone -� <br /> I <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition ✓ Moving o ) <br /> Sanitary ✓ Camping Unit n o <br /> Privy �r / /�, CSubbdivisio-nrryo 0 <br /> Structure Use: ( �Z//) xa,,//�!O/� <br /> (family homelcabin,garage,addition, c.) o f <br /> m t <br /> Directions for plot plan drawing: <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 lake or flowage- if within 1000 ft.and the location of any river or stream -if within 300 ft. 0 <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. Pro.td. legal description (o.. to.. aid. of this Form) tax state-unt. <br /> PLOT PLAN 3 J <br /> a k3 rn <br /> _ c <br /> 33 3 -e3 - gee <br /> N <br /> O <br /> w a <br /> I <br /> d TcoI <br /> N � l <br /> U <br /> s J <br /> m � <br /> 0 <br /> T <br /> N <br /> Z <br /> O <br /> I Z <br /> JJ <br /> m c�mmcDinc� <br /> 9 <° d Cm O O 3 <br /> Z y N O 7 D <br /> d : m <br /> o c I C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o I 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 /> PP (including Yaccompanying ) g n <br /> information contained in this applicationan 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 /> o : <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providingn <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> tD <br /> Jli�o? q� <br /> SIGN HERE �/ E E <br /> (sipKate of owner uilding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N mm <br /> 0 0o oo <br /> oo�Vf <br />