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Burnett County Office of Zoning Administrator m v ti Z <br /> APPLICATION FOR — LAND USE — PERMITS <br /> E; �_ <br /> 3 f <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'Z m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- - c <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. <br /> n <br /> OWNER(Please Print) Contractor or Surveyor o Agent a <br /> J G a v ' 7 a' l wo m <br /> Address y Address = <br /> S '00� <br /> City,State,Zip Code City,State,Zip Code <br /> Gid - '77 ( " <br /> Telephone Telephone ' <br /> Permit(s)Applied for. <br /> New Building ✓ <br /> Filling/Grading (t <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> 0 <br /> m r <br /> Structure Use: — &RA6E o ° <br /> (family home/cabin, garage,addition,etc.) zo 0 <br /> O <br /> Directions for plot plan drawing: a <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 <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 /> PLOT PLAN o <br /> 3 <br /> o a <br /> Y) <br /> R, <br /> f w� <br /> cob; <br /> i <br /> 90Z <br /> i <br /> S <br /> R <br /> 1 VqN i3h aC1p <br /> ;I r� o <br /> Z <br /> D <br /> V <br /> T <br /> cow 0 <br /> i <br /> f m c�yiunn <br /> / p 0 <br /> m <br /> 6 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all o <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that n � G <br /> X�: i <br /> this information I accept <br /> providing will be relied upon s the County n 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 y this information I am providing <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 /> T <br /> SIGN HERE <br /> (si a re of owner building contractor) (date) R :' <br /> lJ <br /> ZONING ADM INISTRATOR ` o: o <br /> TOWNSHIP PERMITS AY BE REQUIRED N o' <br /> 000.06' 6 <br /> 00000 0 <br />