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L3!' <br /> Burnett County Office of Zoning Administrator /£ 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 - c <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 /> tions of the State of Wisconsin. w m <br /> C m <br /> OWN R PIXQ Print ii 0 <br /> ���� 1 Contractor or Surveyor or Agent 5 <br /> Gbldj�:ON w <br /> Address Address m <br /> J'T 1 ,4�0iI' X07 I <br /> =CI tat Zip de Z City,State,Zip Code <br /> spz�fz ,U/�,T s�d'93 <br /> Telephone ® to 7 Telephone <br /> Permit(s)Applied for. <br /> New Building FillinglGrading <br /> Addition Moving o ^\ <br /> Sanitary Camping Unit l 1 <br /> Privy A/1' Subdivision o <br /> •0 _ <br /> w <br /> Structure Use: vn/^/\I e� L 0 <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). <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 /> O <br /> a <br /> Z <br /> O <br /> 90� Lj � � � �2� � b <br /> N <br /> 00 <br /> w <br /> I O <br /> Q � <br /> a � <br /> J N <br /> w <br /> 1 <br /> Zm <br /> Z <br /> O <br /> Z <br /> S <br /> m c�mm�ac�� <br /> y' � mozn — <br /> Z <br /> o � : , <br /> Q <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the i m <br /> detail and 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 q <br /> County of Burnett relying on this information I(we)am(are)providing in this application. I(we)agree to permit county offi- :a <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- ` imi <br /> mises at any reasonable 91ne for the purpose of inspectio m ' i <br /> w i <br /> ert: <br /> SIGN HERE cp 9rdpOi` o i j o <br /> (signal of ow r or krwildj'aQ contractor) (date) <br /> ���75 <br /> ZONING ADMINISTRATOR V ' � _ <br /> N N O N Tm <br /> NN TN O <br /> OWNSHIP PERMITS MAY BE REQUIRED SSSo�fm/l <br />