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Sumett Cor .ry Office of Zoning Adminis%rator ; m o <br /> APPLICATION FOR — LAND USE — PERMITS3. UQ <br /> ,v o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 00 <br /> c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 a <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. O <br /> e_ c4 Gcr /2� <br /> m <br /> OWNER(Please Print) Contractor or Surveyor or Agent n F <br /> G9ooG/r.�ulea <br /> Address _ Address <br /> City,State,Zip Code City,State,Zip Code <br /> Gfz- <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading , <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy —�X Subdivision o <br /> Structure Use: <br /> t'F I �y o <br /> (famil home/cabin, garage, addition,etc.) Z o <br /> o v <br /> m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). 0 <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 t�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 /> 0 <br /> 3 r <br /> v o <br /> of <br /> �� N <br /> v\ c <br /> v <br /> n <br /> 1 < s <br /> y. <br /> 7S_ <br /> Prl�y =� Co <br /> m n <br /> ts= 0 0 <br /> N � <br /> Z <br /> O <br /> Z <br /> 11ItI7J <br /> I <br /> 70 rDDWMI <br /> oc�i `—m <br /> mnma';S]0 <br /> 0: o o On <br /> o � <br /> «[ [ 2 m <br /> n : E O <br /> o [ 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 : E E m ; ' 71 <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible forte ; m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (me) ' 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 oft e <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county oil fi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described p e- <br /> mises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (sig of owner or uilding contractor) (date) <br /> o: <br /> ZONING ADMINISTRATORL-�' fns <br /> N NN <br /> OWNSHIP PERMITS MA BE REQUIRED o�B000M <br />