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Burnett County Office of Zoning Administrator ; f f 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 w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 0. <br /> nett County Land Use Ordinanc nitation Code nd with all other applicable County Ordinances and the laws and regula- <br /> do f the S to of Wisconsin. <br /> f'Sn O <br /> OWMT�(Pleasee Pr'rpq Contractor or Surveyor or Agent a �F <br /> w m <br /> LAI' C �13� Address <br /> City/St) ;te,1 Cod 2-s 13 3 6- <br /> 7 7 V City,State,Zip Code cx� , <br /> Telephone Jl rPJ Telephonero[ <br /> Permit(s)Applied for: u <br /> New Building Filling/Grading <br /> Addition Moving DQo <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 ,.�"� <br /> N v <br /> Structure Use: I 64-,?qq On I-11' 0 <br /> (familyhome/cabin, garage, addition,etc.) Z o CJt <br /> 0 o Q <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. o fi <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. (7 <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 /> a (((yyy o <br /> Z [ <br /> o ? <br /> c A� , <br /> I a <br /> rn <br /> J 0 <br /> w � <br /> I � <br /> 'm <br /> Z <br /> O <br /> Z <br /> �ce Cnndl -6o a� PrO1 <br /> ry 0T rm 203-0 <br /> wE ? �o �m' 3 <br /> oZ <br /> Nn:: iA <br /> C O <br /> epi <br /> ci C <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 J=- 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 <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 /> W <br /> SIGN HERE <br /> (sigpe(ure of owner building contractor) (date) <br /> ZONING ADMINISTRATOR _ N o L N rtt <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED S o 000vmi <br />