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Burnett County Office of Zoning Administrator ;m Z <br /> APPLICATION FOR — LAND USE — PERMITS <br /> z21 s <br /> TO 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 /> 3 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. w m <br /> c O <br /> OWN(skl(Plv�ease Print) ConWco or�r Speyo�r Ag�t, o. <br /> Address Addre s = 1 <br /> � -Q 0,- IJrS <br /> CityState,Zip`CI In ( <br /> ) , City,State,Zip Cod— \j <br /> ( , 4 N 1Q, 'b U � W 1 .S7 ri y� <br /> Telephone Telephone V`�/, <br /> Permit(s)Applied for. <br /> New Building _ Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 t <br /> w <br /> Structure Use: e^1r o <br /> (family home/cabin,garage,addition,etc.) o 0 <br /> a <br /> m <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. o <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. 1 <br /> o <br /> r <br /> 0 0 <br /> Z <br /> —._ o <br /> I <br /> __.. fes_.. <br /> 9" <br /> V � N <br /> c <br /> a <br /> V o <br /> N <br /> m <br /> m n <br /> O O <br /> o <br /> m <br /> o° <br /> U I30 __j , _ <br /> a _: iu cwo�3 <br /> N Z N O >0 . <br /> D <br /> M <br /> G <br /> o: c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o: m <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) n; <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- x„ <br /> mises at any reasonable time for the purpose of inspection. ' io i <br /> Qj SIGN HERE <br /> (6 <br /> Q y a <br /> ( i re of owner or bui Ing c ntracto0 (date) <br /> ZONING ADMINISTRATOR ' <br /> NNOIJ� N <br /> Ut Ut Ut Ut O !P <br /> mp <br /> OWNSHIIP PERMITS MAY B EQUIRED oSo80 of <br />