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T <br /> Burnett County Office of Zoning Administrator m ' o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z s W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and H <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 /> f,C o <br /> ti ns of the State of Wisconsin. m m <br /> OW ER Please Prin Contractor or Surveyor or Agent n f <br /> �t ( o <br /> I (0 9 S ve,4 ao r� " <br /> Address Address fD V <br /> --Fly/J`,"' 1--re�CeyN � 5. 30� V� <br /> City,$tata,Zip�Code City,State,Zip Code t <br /> Tele' one Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> N v' <br /> O <br /> Structure Use: v <br /> family home/cabi ,garage,addition,etc.) 0 0 <br /> c <br /> m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). _ 7L o <br /> 2. Show the location of the well (W) septic tank(ST),and drainfield(DF). ..0 <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 /> 3 r <br /> -P Iia 0 <br /> Z -r> <br /> d <br /> L � Im <br /> n <br /> I F W <br /> 0 <br /> W <br /> s 3 <br /> N <br /> 0 <br /> Sp. Aqa t,,J . �raKO) -4 21 <br /> 21 <br /> Z <br /> 1) mvrnr DDW� <br /> 00 v<> > oa`--m <br /> m a� -�nm ,:aS <br /> o < p1cwo�3 <br /> W w O O m <br /> ' (n M <br /> m <br /> 8 <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 m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) iO <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 <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <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. <br /> SIGN HERE <br /> (sig ture of owner r building contractor) (date) i o, ? ? $ <br /> ZONING ADMINISTRATOR v o m <br /> v v o00 <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 o 0 0 o rm/! <br />