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Burnett County Office of Zoning Administrator l E o <br /> APPLICATION FOR — LAND USE — PERMITS m o <br /> TO THE 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- 3 n <br /> net unty land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> of the State OfWi const <br /> V <br /> c <br /> I Please PE'a) 7 Contractor or Surveyor or Agent f <br /> resaf ,, X� Address m ` <br /> (,ity,State <br /> Zip Code City,State,Zip Code <br /> Tel�r one Telephone .21 <br /> Pem� fy)Applied for: <br /> New Building Filling/Grading <br /> Addition X Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision c <br /> Structure Use: ), 'I,, / o / 1(1 a 1\ � <br /> (family home/cabin,garage,addition,etc.) Z o <br /> 0 <br /> m AO <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). A <br /> 3. Show the location of any lake or flowage-if ithin 1000 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. 1f+ <br /> 5. If,separate plans are submitted by an archi ct,engineer,builder,contractor,etc.,the plans must be signed and dated by ,`hl <br /> the owner. <br /> e tilt i(3 3 0� � <br /> Z <br /> ,b Q <br /> In <br /> o n <br /> w <br /> =y C�AieAlV- <br /> N <br /> u If <br /> m <br /> yp 0 r $ <br /> p� T <br /> 75 <br /> h L <br /> f <br /> —Seer'� <br /> lie H <br /> Q <br /> m cp mg N+ g rDinc� <br /> .( m GOR a <br /> a9 <br /> �4N JTRW FaM IT <br /> P z :.' <br /> y y m <br /> m <br /> g c ? C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of `g; ? @ <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the i m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <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 thei i i f o! <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 ordinaAces orother authorized person to have access to the above described pre- <br /> mises at any reaso a time for the purpos f inspection. mi i i a '• '• <br /> y to i•r: : <br /> SIGN HERE <br /> I a r of ownerui`ding contractor) (d te) �'• - c <br /> 8 o <br /> ZONING ADMINISTRATOR - i to 71 <br /> M <br /> NNf�TN 0o <br /> OWNSHIP PERMITS MA" REQUIRED 8888$18$W <br />