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BurnettCounty` Office of Zoning Administrator ; M f o <br /> APPLICATION FOR — LAND USE — PERMITS3 ' <br /> ,v o <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of tpe State of y�{isconsjn. m <br /> 1 I`E. �' "� 1'I J I c.V a <br /> 077(Please Print) Contractor or Surveyor or Agent °- � � <br /> li I �� t3 <br /> Address (( �' Address = <br /> I, t !' � I � <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone Jv b <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary '�� Camping Unit <br /> Privy Subdivision a S <br /> ()/UN1�t ()/U �� <br /> � <br /> Structure Use: / ° <br /> (family ho a/cabin, garage, addition, etc.) Z o <br /> o v <br /> 1. Show the location and size of all existing buildings(E8)and all new buildings(NB)and indicate North(N). — .c 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. 0 <br /> O <br /> 3 <br /> a o <br /> k- c{. I o .. <br /> zy sad r r co m <br /> 4- <br /> 5' <br /> w <br /> �I to <br /> 3 � ITl <br /> 0 <br /> Cn <br /> m ° <br /> I <br /> It :C <br /> Z O <br /> Z <br /> 1 s\ <br /> M N N DDcoy <br /> mc m n n c m <br /> m n� ' ° n- <br /> m <br /> om: o �' 3 <br /> Z <br /> w S]� c [ m° : O <br /> o: <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 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- U <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the 1 <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offs. <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. 2 <br /> m <br /> SIGN HERE ' !e <br /> ( ' lure of owner or 'Idin contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> �, TOWNSHIP PERMITS MAY WE REQUIRED �000 000fA <br />