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Burnett County Office of Zoning AdministraVr -wo 0 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS d <br /> z s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -o io <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- <br /> tions of the State of Wisconsin. <br /> ��Lc�/.✓ L �f+ �, f mnm <br /> A lL GtTEP r" <br /> OOWNER Please Print) eSLASJKtContract F�roru <br /> S o nJ d <br /> Address Addrgss 01 �? <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit 0 <br /> Privy Subdivision � ' {7/ o <br /> N <br /> Structure Use: � <br /> (family home/cabin,garage,addition,etc.) o o <br /> / m <br /> 1. Show the location and a 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, Y��v/�))) <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. _ Q <br /> ._. ._.. .. ( r <br /> o ` <br /> --------- _. .... 3 <br /> Z <br /> 0 <br /> ,V N <br /> w a <br /> C <br /> V/ <br /> M $ C <br /> CA0 <br /> l <br /> i <br /> o <br /> w <br /> Z <br /> 0 <br /> z <br /> vfe- D <br /> � e <br /> aq n=ELM <br /> o O <br /> 1 <br /> d' 2 i i m <br /> I1`S' c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of W o ; E m : M <br /> my(our) knowledge and belief it is true, correct and complete. I(we)acknowledge that I(we)am(are) responsible for the _C ? In <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- 4.1 <br /> �' <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the i i <br /> Cj <br /> C'3County 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 xtgLonable ime for the pur a of inspection. <br /> m <br /> r <br /> SIGN HERE <br /> ( nat a of owner or b contractor) (date) <br /> STo f f o <br /> ZONING ADMINIRATOR <br /> (NfItTN 00 <br /> TOWNSHIP PERMITS MA40BE REQUIRED SSSSSS <br />