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e"2�� . <br /> Burnett County Office of Zoning Administrator c _M0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> w ' <br /> 70 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v w <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 /> tio s of the State of Wisconsin. o <br /> pfII XV Al If SCI N' SELj c m '�V <br /> OWNER(Pleafie Print) Contractor or Surveyor or Agent n f <br /> / `/La Ny TrMrtFFcF Da �� o <br /> Addressm <br /> Address !?- <br /> Ros 1- U I( Er k n1 S S/o3 <br /> City,State,Zip Code City,State,Zip Code <br /> / A/2j L 39—o3cv 0 <br /> 1'elepholle Telephone <br /> Permit(s)Applied for: 1 <br /> New Building T FillinglGrading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit m <br /> Privy Subdivision c <br /> Structure Use: CA 161, Ne /V �) o <br /> amily homelcabin, garage,additio tc.) Z <br /> 0 v <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). 4 <br /> 3. Show the location of any lake or flowage-if within 10DO ft.and the location of any river or stream-if within 300 ft. r <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 /> -A- e.� S__ 3 r <br /> ,Ud. o <br /> L Co <br /> n <br /> O <br /> w <br /> ` o <br /> Gp b 0 <br /> ina o 0 <br /> xWy / U J U <br /> W <br /> tool UG <br /> 70 X4 Qtlt=4 -I <br /> > l�v 2 N- o <br /> Z <br /> 3 <br /> 0 f <br /> /5'f.55 A,9y �ee Saf.'6=y e.y A c m u+ D >> W10 <br /> n o » o n-m <br /> 3 <br /> N; <br /> s »' m <br /> E1 A <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 <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 E QE <br /> County of Burnett relying on this Information I(we)am(are)providing in this application.i(we)agree to permit county offi- <br /> clals charged with administering county ordinances or other authorized person to have access to the above described pre- i i E E i <br /> mises at any reasonable ti a for the purpose f Inspection. m i i iAll <br /> ? E <br /> SIGN HERE Ad��0 <br /> (signs of owner or bull g c rac <br /> (date) <br /> 8i e <br /> ZONING ADMINISTRATOR T <br /> NNO J: m <br /> NV NO O <br /> WNSHIP PERMITS MAY BER IRED 8888 8 tmn <br />