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Burnett County Office of Zoning Administrator 'o f o <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c -� <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 WisconsinL. TL a <br /> w m <br /> /C2N <br /> ny c 4> C. <br /> OWNER(13flease Print) Contractor or Surveyor or Agent n ili <br /> M; STi 2 G/ cv? , o <br /> Address Address = <br /> City,State,Zip tode City, State,Zip Code <br /> /�!1- - 7,7 —. Yds,/ <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building ><-- Filling/Grading <br /> Addition Moving v <br /> Sanitary Camping Unit <br /> Privy Subdivision <br /> Structure Use: - / 0 <br /> (family home/cabin, garage, addition, etc.) Z o — <br /> 0 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 /> 0 <br /> 0 <br /> 3 <br /> 0 0 <br /> Z <br /> 0 <br /> C` <br /> C rn <br /> ^ � c <br /> a <br /> 01 <br /> o� <br /> 3 N <br /> � m <br /> m o <br /> v o <br /> N � <br /> Z <br /> `\ 0 <br /> Z <br /> G <br /> :o U)M W r'D amy <br /> o v<> >onc-.m <br /> o <'� 01croo='3 <br /> Z O <br /> O <br /> O : <br /> .n[ i 2 ': . m <br /> ' o : D <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of 0y, 'm <br /> my(our) knowledge and belief it is true, correct and complete. I(we)acknowledge that I(we)am(are)responsible for the 5 m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and (we) D <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 a <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- [ <br /> mises at any reasonable time for the purpose of inspection. <br /> m <br /> vi :rrE <br /> SIGN HERE , �/ V ] ' �' N <br /> rq'sig <br /> ture of owner or ildin co tractor) (date) <br /> ZONING ADMINISTRATOR 1." In <br /> � IVNOIJ+ N <br /> TOWNSHIP PERMITS MAY REQUIRED 0 0 0 0 0 0 <br />