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Burnett County Office of Zoning Administrator ; 0 f o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <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- 3 n QQ <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 ofconsin. m m <br /> 0 <br /> OWNER(PI ase Print) ContS rveyor or A nt °- <br /> _ iarP I� Y- w <br /> Add Addre � <br /> VEL �IQn ar I]rsol <br /> City,Sidle,Zip Code City,Staid,Zip Code <br /> Telephone Telephone A[l <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving v <br /> Sanitary Camping Unit <br /> Privy Subdivision <br /> w <br /> Structure Use: o <br /> v <br /> (family home/cabin, garage,addition,etc.) o 0 <br /> D <br /> N <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). .zc 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 /> O <br /> 3 <br /> O <br /> A4,a <br /> o <br /> w <br /> J <br /> 0 <br /> J N <br /> m <br /> (p .A <br /> v o <br /> N J <br /> ti <br /> I Z I( lt <br /> Z <br /> O <br /> Z <br /> JIII9 <br /> I <br /> M c m w n c <br /> m nm auA <br /> N `Z N Q J fG <br /> Z Q <br /> O Ji co <br /> � <br /> Et M in - c m <br /> qjb: <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of M0 <br /> my(our)knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for the v ': 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 the 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 ordinances or other authorized person to have access to the above described pre- Ems <br /> mises at any reasonable time for the purpose of inspection. ` ' '�'• <br /> m <br /> SIGN HERE " "- <br /> o <br /> (s''Mature of owner or building contractor) (date) [ o E o <br /> ZONING ADMINISTRATOR <br /> NNOIJ+�N� <br /> in in<n cnoocnm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 o g o 0 o vmi <br />