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Burnett County Office of Zoning Administrator 0 m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and a 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 <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. m m <br /> m E c <br /> OWN (Please Print) Contractor or Surveyor or Agent n F <br /> d <br /> Address 1 Geo X ROA Address m <br /> City,State,Zip Code City,State,Zip Code <br /> W F13STER \1.11 5489 <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit <br /> Privy 7 f� Subdivision o <br /> Structure Use: l'� A IR R G E x 3f o <br /> (family homelcabin, garage, addition,etc.) z <br /> o ° <br /> a <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. 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 /> a o <br /> Z <br /> 0 <br /> I <br /> C7 <br /> c � <br /> n- <br /> 4 N <br /> v <br /> O <br /> O. O N <br /> L� X <br /> p0 .10To <br /> _ a rc Gi1vF <br /> Z <br /> P <br /> Z <br /> R� D <br /> c=wWancm <br /> m n•< — nm ^;nom <br /> n 2 m o 3 m <br /> o � <br /> In <br /> o f c P C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of A <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the ^; In <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) 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 Ed <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- Em <br /> mises at any reasonable time for the purpose of inspection. m <br /> I° +i <br /> SIGN HERE <br /> o <br /> (s' atu)a of owner 09bu ding contractor) (date) <br /> ZONING ADMINISTRATOR <br /> NNOIV� N <br /> NIT(T InO N <br /> TOWNSHIP PERMITS MAY BE REQUIRED 00000 0 <br />