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. 1 <br /> urnett County' Office of Zoning Administrator d o 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> 3 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> ocated as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. Rt <br /> m o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> 2555 f 5� . Sf1✓�h1 7O ,4 <br /> Address Address n <br /> /1lc', Sslo� <br /> City,State,Zip Code City,State,Zip Code ( U <br /> `^C <br /> Telephone Telephone —r <br /> i <br /> Permit(s)Applied for: �- <br /> 1 <br /> New Building Filling/Grading <br /> Addition Moving g <br /> Sanitary Camping Unit o i <br /> 4 <br /> Privy Subdivision 0 <br /> m r <br /> ` o <br /> Structure use: -dam AAA Z � ^ <br /> (family homelcabin, garage,addition,etc.) o B U l <br /> a <br /> Directions for plot plan drawing: n <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 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 ^or, <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, ;J <br /> river or stream,if applicable. !/) -,,l <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. a <br /> 6�L �g� a legaldescription on the side of this form) as on tax statement. o m <br /> �`CAl7- Z n <br /> 1 y • - � <br /> t , V <br /> r r <br /> 560-Cg?" <br /> ffil- <br /> 21 <br /> n <br /> G\� ^ <br /> Z <br /> O <br /> Z <br /> I IDf1 <br /> M NV Nr DD co-0 <br /> m0 a a m <br /> 0 O a-' <br /> ` imp 3M <br /> 0 o m42 : <br /> D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my V o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that ` tJ <br /> PP (� 9 Y ) 9 A <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a -j <br /> permit.1 further accept all liability which may be a result of the County of Burnett relying on this information I am providing lTl n <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized : <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> S t m b <br /> SIGN HEREA3i <br /> (sign a of ow`n'e/r//�Jbui lding contractor) (date) ' ` N <br /> ��� %�2F% P: o <br /> ZONING ADMINISTRATOR _e_'.:�K/��( <br /> NNON Nm <br /> TOWNSHIP PERMITS MAY BE REQUIRED ° oo n n o m <br /> Ba J y <br />