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Burnett County Office of Zoning Administrator d o o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <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- <br /> tions off'the State of Wisconsin. <br /> ,� o <br /> F -&)1- i� U- �C�171�/2 1 � (,y <br /> 0 ER Please Pr'nt) Contractor or Surveyor or Agent <br /> Ad es,� �. .. Address ice. <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> r� <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Additions Moving o <br /> Sanitary Camping Unit O <br /> O <br /> Privy Subdivision 0 <br /> j-- o o <br /> Structure Use: r p/V 1 /7�� v <br /> (family home/cabin, garage,addition, etc.) 0 0 <br /> a pti <br /> m v 1 <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 take 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 /> theowner. 6. PROVIDE LEGAL DESCRIPTION AS SHOWN ON YOUR TAX STATEMENT. <br /> O <br /> 0 <br /> PLOT PLAN 3 <br /> � N <br /> Z Q <br /> o� a <br /> N <br /> 0 <br /> VIV <br /> t <br /> n <br /> O <br /> e� . o( �rarvi`n�s o <br /> J <br /> 0 <br /> T <br /> N <br /> Z <br /> O <br /> 1 <br /> OM ✓- 1H4 S S "A"C �LO� TJ C�7vM � M (nvmr-DDW-a <br /> mo Q<> > 00 aac m <br /> m o. c -ani <br /> a y p 0 6j(pp ic <br /> Z O •� <br /> m <br /> o E O <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my � <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that A ma ; p <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 <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> �7" m <br /> SIGN HERE e 1 4 4 . C <br /> (signatu of owner or building contractor) (date) <br /> o: o <br /> ZONING ADMINISTRATOR o o <br /> n-n <br /> TOWNSHIP PERMITS MAY BE REQUIRED M"renmooc m <br /> 0000000vmi <br />