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Burnett County Office of Zoning Administrator d 0 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d a <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 m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n O <br /> tions of the State of Wisconsin. m o <br /> -r ^ _ C A <br /> eff uT fY3 � trt a O <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> m `e <br /> Address Address 1 <br /> n l t 1 c V <br /> City, tate,Zip Code City,State,Zip Code <br /> I o <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o �� <br /> Sanitary Camping Unit o <br /> !\ <br /> Privy Subdivision 0 <br /> ;vuStructure Use: <br /> (family homelcabin,garage, addition,etc.) o 0 <br /> m <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. <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 /> 6. rove a legal description on the side ot this orm as on tax statement. O <br /> PLOT PLAN <br /> a rn <br /> c <br /> P a <br /> 0 0 <br /> C� J <br /> / rrt <br /> � = <br /> 0 <br /> u4t <br /> N <br /> O <br /> T � ill,♦V` <br /> y <br /> �s . T' <br /> Z <br /> � <br /> mrDDm� <br /> RA <br /> 'mm Z N O > p <br /> OZ ? m Z <br /> N: : m <br /> m <br /> 0 A <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <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 /> information contained in this application(including an accompanyingschedule and I further declare that I reco nize that O <br /> PP C 9 Y ) 9 <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 N <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized o <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> r <br /> m <br /> ^-zn ,_.. <br /> SIGN HERE Ste- <br /> /era- of own building contractor) (date) <br /> 00 <br /> ZONING ADMINISTRATOR <br /> m <br /> TOWNSHI-- MITS MAY BE REQUIRED <br /> m <br /> Noo,cii <br /> 00000fmA <br />