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,x,-70 . <br /> Burnett County Office of Zoning Administrator 'WoM f o <br /> APPLICATION FOR — LAND USE — PERMITS Q, 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -o 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of thle Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and r)?gula- <br /> tions o e State of Wisconsin. , m D <br /> �erry 'T � tlllsan <br /> 0 <br /> OWNER Ple�rint) Contractor or Surveyor or Agent o. F <br /> ko'A �-c g." 200 d A <br /> Address Address f° <br /> City State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving a <br /> Sanitary Camping Unit <br /> Privy Subdivision <br /> Structure Use: Ad f 4 o j <br /> (family homelcabin, garage, addition, etc.) o 0 <br /> m <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 t�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 dajtad by <br /> the owner. <br /> O <br /> 0 <br /> 3 r <br /> a o <br /> Z fD <br /> O r <br /> NI <br /> OI n <br /> � P <br /> W O1 <br /> o J <br /> 0 <br /> J R <br /> 0 0 <br /> IGF► G�c�V 1 �" <br /> T tel` <br /> Z Qi <br /> O <br /> Z <br /> a <br /> F <br /> Co <br /> 'O <br /> d C N0 . <br /> O 7j <br /> o: 0 : <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the eii of <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for the 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 3ur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county ffi- <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. T ' <br /> SIGN HERE ✓�^^""' '' `� [ of E [ o <br /> gna of owner orb ing co tractor) (date) <br /> ZONING ADMINISTRATOR <br /> 11I)� u s P cn o m <br /> WNSHIP PERMITS MAY;E REQUIRED o 0 0 0'o fn <br />