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Burnett County Office of Zoning Administrator m „ Z <br /> Mm 0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> w ' <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m o Z <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> 0 c W <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 M <br /> tions of the State of Wisconsin. _ <br /> _ DAV10 DgJtf c <br /> OWNER(Please Print) Contractor or Surveyor or Agent n z FO <br /> 110450 BaNICAPORT 5r /`F 0 <br /> Address Address = <br /> HAm LJiYr- tM►j <br /> City,Stale,Zip Code City, State,Zip Code <br /> (e1X-434 - )144 �. <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o C <br /> Sanitary Camping Unit O <br /> Privy Subdivisiono 0 <br /> 0 » <br /> m r <br /> Structure Use: <br /> o <br /> (family home/cabin, garage, addition, etc.) z0 o <br /> 0 <br /> m <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). _ <br /> 2. Show the location of the well (W), septic tank(ST),and drainfleid (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 '� J <br /> the owner. <br /> rov a ego description on a side 51 E� m PLOT PLAN tax statement. o <br /> 3 <br /> -P C rn <br /> /- 0 o a <br /> V <br /> �g 1 <br /> ��O v CRgttJ t <br /> a <br /> ,y61 QCOZ4 0. <br /> •6'X <br /> pgwy KF'�� j 'J,1:aio <br /> Cq o J <br /> rlosrl' / 0 z <br /> c: 60 <br /> ot � ' f u:�llr iv TA2 : m <br /> of p <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best ofmy �. c: C <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all W <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that ` A : m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a ` 'o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> ^ A <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR c bo <br /> TOWNSHIP PERMITS MAY BE REOUIREDN o o v m <br /> O V N <br /> C 888'0 CA <br />