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Burnett County Office of Zoning Administrator ; f o <br /> APPLICATION FOR — LAND USE — PERMITS 3. ° <br /> u o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and - 00 <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 /> tions of the State of Wisconsin. m m <br /> J-1c,FLEP. WAAQ pm = <br /> c <br /> m O <br /> OWNER(Please Print) Contractor or Surveyor or Agent 0. <br /> 413,1 X&AL)o e 0 1417E n• <br /> Address )l / Address <br /> 4T'Louis K+'Zr_v ✓/'/r1 , SS<L/lo �/' <br /> City,State,Zip Code City, State,Zip Code ( ^, <br /> Telephone 9_ �Z,,fO Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> n <br /> Privy Subdivision 0 _ <br /> ' (f _ 0 /n <br /> Structure Use: G'g Kh G� <br /> 14 19 <br /> I I / — ° <br /> (family home/cabin, garage, addition, etc.) z vo <br /> o ° <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 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 /> 0 <br /> `fit LqK� o <br /> Z <br /> 0 <br /> �--�—� <br /> /00 IF <br /> L ► <br /> q 7S r <br /> I t 0 <br /> \lyNlj � <br /> f N` <br /> O <br /> m 0 O O <br /> t \ ` <br /> d <br /> 7SG/ <br /> � I � <br /> C <br /> c-f <br /> 7] N17Nf-DDOOV <br /> a = <br /> Co 6 <br /> - -- -- � �, ° mm3 <br /> /00 I 0 O: <br /> .11..- r_p: 31 <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 y`E m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) [ ici ' 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- l <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the a <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- >a' <br /> mises at any reasonable time for the purpose of inspection. '• `'" <br /> SIGN HERE <br /> ( g ature4f ownerr uil (date) <br /> 'n contractor) - - <br /> • b: o <br /> o: o <br /> ZONING ADMINISTRATOR is iso N-n <br /> Nm <br /> TOWNSHIP PERMITS M BE REQUIRED y <br />