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BurnetYCtiunty Office of Zoning Administrator m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 00 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 C, ' <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - _Q <br /> tions o the State ofrr! onsin. m a <br /> O ER Please Print n O <br /> ( ) Contractor or Surveyor or Agent E <br /> AdQQ��ss 1t�o Address �? <br /> City,State,Zip Code City,State,Zip Code <br /> '34� <br /> Telephon � � <br /> e Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading y� <br /> Addition Moving <br /> o <br /> Sanitary _ Camping Unit 1��1 <br /> Privy Subdivision 0 <br /> �n�u m <br /> Structure Use: ��'(11�1`V o <br /> (family home/cabin, garage, addition, etc.) z <br /> P ° <br /> v <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). L `- <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. 904. 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 /> 3 <br /> a <br /> ��r� z naso <br /> V <br /> N <br /> a <br /> 73 <br /> m <br /> a o <br /> it i M(c,C � D ^vD <br /> 70Z <br /> 0 <br /> Z <br /> f recd rm, ]DEW, n�dw�a'oma-�°.m <br /> � <br /> 0 a� =- <br /> mamas <br /> '^ y'[ wo �o= 3 <br /> z <br /> o <br /> nnaavves� <br /> Itail <br /> e)declare Nat this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> (our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the <br /> 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 i i im <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- :m: <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reas le time for the purpose f inspection. a i <br /> SIGN HERE rA A A �fJ D E <br /> si ure of own o con ractor) <br /> S o <br /> ZONING ADMINISTRA R I & i ' T <br /> N, S oouNmn <br /> TOWNSHIP PERMITS Y BE REQUIRED S S SSS vi <br />