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Burnett County Office of Zoning Administrator 00f o_ <br /> APPLICATION FOR — LAND USE — PERMITS m o <br /> TO Tk;E ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- o. Q <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tion ss,,-ppf the State of Wisconsin. w m 1 <br /> l/Iy'4) <br /> n o <br /> OWNER(Please Print) �� Contractor or Surveyor or Agent "� f <br /> d � _ <br /> Address Address t <br /> de City,State,Zip Code <br /> City,State,Zip Co <br /> V <br /> Telephone Telephone �l <br /> Permit(s)Applied for: <br /> New Building Filling/Grading , <br /> Addition Moving p <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> E ` l <br /> /N ° Nom" <br /> Structure Use: Cdj)� n <br /> (family homelcabin,garage, addition, etc.) a o <br /> D <br /> N <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 a architect,engineer, builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. \\ <br /> 3 <br /> 1 v <br /> o <br /> a <br /> o <br /> Q <br /> Lit <br /> o <br /> 4 <br /> o o <br /> J <br /> 7 „ <br /> 0 <br /> IN <br /> o <br /> lnvNrDDWm <br /> \\\\ m ❑ .mmoac m <br /> m a� C: n om <br /> c w <br /> on U M^C /".3 1, A d� y <br /> l 1�1G t 7J TJ 70.v / O EFW M <br /> // ?n Ei i o m <br /> /I W qi'Gr In <br /> I(we)declare that this application(including a y accompanying schedule)has been examined by me(us)and to the best of 0 ; a <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the fm <br /> 11 <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 i o ': 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- Wi E <br /> mises at any reasonable time for the purpose of inspection. <br /> iA <br /> SIGN HEREJW <br /> ( ' ture of owne r ui`lding contractor) (date) o o <br /> ZONING ADMINISTRATOR .C"�/ - 'tV e� N N OIV N T <br /> NIT <br /> boafTO IT <br /> TOWNSHIP PERMITS MAY BE REQUIRED `Qoo �] <br /> B000000 C <br />