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Burnett County Office of Zoning Administrator c 0 £ o <br /> APPLICATION FOR — LAND USE — PERMITS3- <br /> z s <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- 3 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tion -of the State of Wisconsin. �. o <br /> 61A/� .�i9fi1A�e7YlLC- m <br /> m <br /> OWNER(ease Print) Cont ctor Surve or or Agent 0. F <br /> X35 man tamed,! Aw , 7f� 0 <br /> Address Addre <br /> �i�,i='p �i i mN RID _Z(en <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone O <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o' � <br /> J <br /> w <br /> Structure Use: <br /> (family home/cabin,garage,addition,etc.) z <br /> 0 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. <br /> 6. GIVE LEGAL DESCRIPTION AS WRITTEN ON TAX STATEMENT. <br /> 0 <br /> 0 <br /> 3 <br /> v o <br /> 2 <br /> Ila - IIS � <br /> N <br /> ' <br /> o I a <br /> w <br /> L ` J <br /> l C � <br /> 9 N <br /> A) m <br /> O <br /> N J <br /> Z <br /> a <br /> Z <br /> D <br /> m <br /> co <br /> m a� 'nm anA <br /> Cc <br /> o J <br /> g? i c. C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <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) I i i ' : 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- t�< a <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- ; in <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- : a i <br /> mises at any reasonable time for the purpose of inspection. <br /> w i <br /> SIGN HERE r E N <br /> (si at re of owner Ar building contractor) (date) <br /> ZONING ADMINISTRATOR E v,rtl <br /> V•[TN(TOOfI <br /> TOWNSHIP PERMITS MAY BE REQUIRED 000 Sgo S(mR <br />