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L7t cn-/7), <br /> Burnett County Office of Zoning Administrator ; m o 0 <br /> APPLICATION FOR - LAND USE - PERMITS <br /> a <br /> m <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v u 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 cm 0j <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 <br /> nl(f/�A/ Gal—Al DRm a.t/ .rC A •AAIC,-e ,&_XC,4 0,47 %V 6 � != <br /> OWNER(Please Print) Contractor or Surveyor or Agent a f <br /> AAPdress Address �? <br /> Sm . 5J. /na9u( /I1%.V.v. 4a5 73 aPf/-LL LOVlez`r U/is .S�y6En <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 o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> 0 <br /> N <br /> Structure Use: m <br /> (family home/cabin, 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. M <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 /> O <br /> 0 <br /> v o <br /> Z <br /> I ' <br /> \ n <br /> o <br /> N <br /> n <br /> T <br /> A <br /> Z <br /> 0 <br /> Z <br /> 11 <br /> a Mvcnr DDm� <br /> m c �.mmmacm <br /> m a Z= m a-. <br /> m a� =am =am <br /> a m : zm0 <br /> Z 0 l -� <br /> y' M <br /> C: : M <br /> of � '• O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our)knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for the <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and (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 '• X,� of <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- a <br /> mises at any reasonable time for the purpose of inspection. <br /> m M: <br /> SIGN HERE ' <br /> (sign re of owner or buil g con act r) N' - ) (date) o [ o <br /> ZONING ADMINISTRATOR / .� UY(YYII i ,n <br /> PP oocNnm <br /> 00 5060 <br /> TOWNSHIP PERMITS MAY BER UIRED� 0 0 5060 <br />