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Burnett County Office of Zoning Administ ator f o <br /> APPLICATION FOR — LAND USE — PERMITS d 3 0 <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describel and m w ---� <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of th Bur- 3 Co .._j <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and r gula- — <br /> tions of the State of Wisconsin. <br /> OWNER(Please Print) Contractor or Surveyor or Agent n f <br /> o _ J <br /> A ress < Address '? <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving v <br /> Sanitary Camping Unit <br /> Privy X Subdivision o <br /> J <br /> N (hv <br /> Structure Use: I ° <br /> (famil home/cabin, %hrage,addition,etc.) Z <br /> o ° <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). <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 tc 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 dat d by <br /> the owner. <br /> o <br /> 'P <br /> Z <br /> 0 <br /> I <br /> �eef �ea� t I s— a <br /> t <br /> of <br /> ° <br /> J N <br /> m ° <br /> 0 <br /> !TV <br /> J Z <br /> O <br /> rn <br /> Z <br /> m 'nm an 0 <br /> o C o 3 <br /> Pi ` i o A <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best f <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for If e m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (w ) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of B r. <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of tf e <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county of i- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pr - <br /> mises at any reasonable time for the purpose of inspection. <br /> m <br /> � ^ w <br /> SIGN HERE <br /> (sign 6f owner or bui 'ng contractor) (date) <br /> ) <br /> ZONING ADMINISTRATOR Fn T <br /> v. �oocNiim <br /> WNSHIP PERMITS MAY BE WEQUIRED o0 0000fmp <br />