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/W, 622 T 77� . <br /> Burnett County Office of Zoning Administrator ;n m ✓£ o <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> m CU <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describ9d and -p m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and Regula- <br /> tions of the tate of Wisconsin. (� <br /> ie d <br /> OWNER Please Print) Contractor or Surveyor or Agent a £ <br /> Address Address '? <br /> City,State,Zip Code City,State,Zip Code (c11 <br /> '7 � <br /> Telephone Telephone <br /> Permit(s)Applied for: f <br /> New Building Filling/Grading <br /> Addition Moving o (, <br /> Sanitary Camping Unit !, <br /> Privy Subdivision o !� <br /> 0 <br /> Structure Use:SIJ 1 I t CFM CN L 0A <br /> (family h me/cabin, garage,addition,etc.) Z �jW <br /> 0 <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). <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. vo <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 cal ed by <br /> the owner. <br /> o t N <br /> � � a <br /> t y s <br /> 02. h ^ N <br /> m <br /> O p <br /> 7 <br /> A n <br /> V i <br /> In ^ <br /> 'm V" <br /> Z <br /> O <br /> 2 <br /> �l <br /> m c�wm <br /> no ncc-0 <br /> o V< > > a-.m <br /> D m N o mm <br /> y� Z O : : RQ : : 1 <br /> GZ- 1 U/I.uJ�j m m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best f S: A <br /> my(our)knowledge and belief it is true, correct and complete. I(we)acknowledge that I(we)am(are)responsible fort e m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I ( e) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bt r- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of ti e <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county of i- <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 ins action. <br /> m <br /> SIGN HERE <br /> (sigu of owner or by(�I' t tor) (date) �' o <br /> ZONING ADMINISTRATOR N N IOi ' �T <br /> � O L' .N m <br /> (T tPN(TOO(T <br /> OWNSHIP PERMITS MAY BE R OUIRED 88WN 8888um) <br />