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Burnett County Office of Zoning Administrator coo o <br /> APPLICATION FOR — LAND USE — PERMITS '5 3. o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements Of the Bur- n (� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - v- >i <br /> tions of the tate of WisMinn. y <br /> w O <br /> OWNER Plea a Print) Contractor or Surveyor or Agent o. <br /> Je- d <br /> Address, Address <br /> City,State,Zip Code U City,State,Zip Code <br /> Telephone Telephone <br /> �C <br /> Permit(s)Applied for: 'r <br /> New Building — FillinglGrading l <br /> Addition Moving O <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 p <br /> w <br /> Structure Use: /0I"���/dry' o <br /> (family home/cabin, garage, addition,etc.) o 0 <br /> a <br /> w <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). .c 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 an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. <br /> n <br /> 0 <br /> 3 <br /> a o <br /> Z <br /> O r <br /> N - <br /> c <br /> o <br /> � w <br /> m <br /> 0 <br /> w <br /> T <br /> m <br /> Z <br /> O <br /> Z <br /> 9 <br /> O <' wCm0 � 3 <br /> Z Omm _ <br /> O : i y; y <br /> w i =i m <br /> u : C : 0 <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of S <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the — ,� m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) l? 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 ther o i <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- : <br /> mises at any reason I time for the pur ose of inspection. <br /> SIGN HERE ,WT <br /> nat re of owner or bitiWrng contractor) (date) oo E E [ o <br /> ZONING ADMINISTRATO ' <br /> NNOIV-� � <br /> TOWNSHIP PERMITS MAY BE REQUIRED C$88o$ <br />