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Burnett County Office of Zoning Administrator ; m o <br /> APPLICATION FOR - LAND USE - PERMITS 1 <br /> 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -u 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 Wisconsin. <br /> m d <br /> E K aof>— d to l✓ISoft, P 7n- 3 } C/ S <br /> OWftIEPPleas rint)Llwd�©� Contractor or'Surveyor or Agent m <br /> w <br /> AddAddress m <br /> City,State,Zip Code �. p City,State,Zip Code <br /> Telephone Telephone <br /> 7145 <br /> Permit(s)Applied for: <br /> 1 <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit m <br /> Privy Subdivision o <br /> 64n4 3 <br /> Structure Use: X 401 <br /> • o <br /> (familV homelcabin, garage, addition,etc.) Z <br /> oo <br /> 9 <br /> 0 <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. <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 /> Q� , <br /> 3 F <br /> 5 r1L-�CG� Z _ <br /> GQ <br /> 7";- <br /> In 1 <br /> EyI <br /> VA <br /> J y <br /> J <br /> m <br /> O p <br /> N J <br /> .On <br /> O <br /> Z <br /> 70 <br /> purvtnr DDW� <br /> M C .m W O a m <br /> m 'a4 - 'U m R n m <br /> v <' P1 c w 6'53 <br /> N N O J 0 <br /> Z O : Z <br /> m <br /> Yi <br /> OI(we)declare that this application(including anyaccompanying schedule)has been examined byme(us)and tothe bestof -my(our) knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for the [nf m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we)further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur-nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of theCounty of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi-cials charged with administering county ordinances or other authorized person to have access to the above described pre- P i <br /> mises at any reasonable time for the purpose of inspection. <br /> � J w <br /> SIGN HERE Zzif-l u//// <br /> (sig re of owner or bu' n c n actor) (da e) : o o <br /> O: o <br /> ZONING ADMINISTRATOR <br /> NNfOT fNnO fNT <br /> TOWNSHIP PERMITS MAY B EQUIRED 00000 0 <br />