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Burnett County Office of Zoning Administrator. ; m F o <br /> 3 — <br /> APPLICATION FOR — LAND USE — PERMITS z H o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 a (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. 6 m <br /> S (' VtV1 m <br /> � rr.hK o <br /> OWNER(Please Print) Contractor or Surveyor or Agent n kA <br /> Address Address tD <br /> Sr Yu HI Mme . ��1i3_ <br /> City,State,>Zp Code City,State,Zip Code <br /> GIZ L44- 7SLo r <br /> Telephone 7,05-/ 35-9 7706 Telephone <br /> Permit(s)Applied for: d <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit @ q <br /> Privy Subdivision 0 fi <br /> Structure Use: � QK6 WUGO S�OlQQl_ 1dX �o' N s <br /> ° <br /> (family home/ca in, garage, addition,etc.) o 0 <br /> a <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). M <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. t% H <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by 1, <br /> the owner. <br /> dN 5 <br /> 3 G r <br /> a w o <br /> Z < <br /> 0 <br /> P W <br /> s NB <br /> 9J ` <br /> .�y a <br /> Q <br /> � <br /> 8 <br /> 3 _ <br /> N t <br /> N ° <br /> J N <br /> m <br /> rS O <br /> w J <br /> Z <br /> O <br /> Z <br /> Y 1 <br /> 1 H,y6 wafer rv"ak <br /> t W <br /> ro h <br /> V � <br /> � eer � d ke. <br /> mc9ww�nc�� <br /> m nim z o a a <br /> P D C rn O J <br /> j�. N `� N ° J r0 <br /> Z O <br /> O J <br /> N M <br /> oo m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of ` m E A <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are)responsible for the 1 ; 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!i?e for the purpose of inspection. m <br /> m [ <br /> SIGN HERE <br /> of <br /> (si u of owner or ng contractor) ( ate) o <br /> O <br /> ZONING ADMINISTRATOR 0 NON N T <br /> o�ornm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o00 otn <br />