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170 Cant <br /> Burnett County Office of Zoning Administrator 'Wo 'e" <br /> o <br /> APPLICATION FOR — LAND USE — PERMITS o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <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- - Z <br /> tions of the State of Wisconsin. m w <br /> (�,AL PN Coma 1(0/y 1� EC K C 0/1/.5-TCL. Cti AJv m <br /> m O <br /> OWNER(Please Print) Contractor or Surveyor or Agent °- <br /> y355- Edwards C't_ tC! 90X30 d <br /> Address Address <br /> (J.9UENPo�7- -rq 5J 8a� �,fJe � LA /� � �485o I <br /> City,State,Zip Code City,State,Zip Code <br /> 72Y '76 <br /> Telephone Telephone <br /> Permit(s)Applied for: II <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> m <br /> Structure Use: l � ,,yy I^ <br /> (family home/ca[t/�ln,garage,addition,etc.) o o <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. <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 /> O <br /> 3 <br /> Z <br /> O <br /> T <br /> —v U) <br /> °N J <br /> 0 <br /> 3 O <br /> V <br /> D p <br /> o <br /> I � <br /> 21 <br /> �• Nouse <br /> I Z <br /> a <br /> Z <br /> IL D <br /> O I <br /> M mvmoc <br /> M 'a 00nacm <br /> o <br /> m <br /> '9 z € : m <br /> � c ° C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o <br /> �o <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for ther m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) 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- <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- <br /> mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE 00 <br /> '• V <br /> (sigat re of owne r building contract r) V (date) '• ` 9 ` o <br /> ZONING ADMINISTRATOR ` ' m <br /> Jln uNiN�NJ o, m <br /> TOWNSHIP PERMITSYMAY BE REQUIRED oSoo o N <br />