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rIY j <br /> Burnett County Office of Zoning Administrator ; 0 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 <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 /> tio s of the State of Wisconsin. u, m <br /> Op <br /> OWNER(ItTase Print) nn Contractor or Surveyor or Agent a r F <br /> w � <br /> Address � _ � Address <br /> m <br /> 6 ^F <br /> City,State,Zip Code City, State,Zip Code <br /> �E. CVOIx F�il4 Iti'J` � <br /> Telephone -�i5-� 18 � Telephone I A <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit R <br /> Privy Subdivision 0 <br /> Structure Use: rl �.�,� ° <br /> j (family home/cabin, garage, addition, etc.) 0 0 <br /> a <br /> m <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 /> 0 <br /> o V� 4 <br /> Z <br /> (I N <br /> a <br /> 1 = r <br /> m <br /> O Ip„ <br /> Illr`C\i- <br /> I <br /> O <br /> 1n <br /> 7 N <br /> 2 O <br /> N � <br /> w <br /> 1 � <br /> �r✓ <br /> � Z a <br /> o <br /> Z <br /> g <br /> M COy raamy <br /> C ° aim <br /> m a mnn77 <br /> a 5: <br /> o J m i <br /> 2 i m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of _o: 'm <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the [ m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) 1 ?^f ' C <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 �' <br /> Count of Burnett relying on this information we am are providing in this application.I we agree to permit count offi- i <br /> Y Y� 9 ( ) (are)P 9� PP ( ) 9 P Y <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- O <br /> mises at any reasonable time for the purpose of inspection. m <br /> SIGN HERE- <br /> sign ur of owner 0 ng contractor) (date) + o E E o <br /> ZONING ADMINISTRATOR T <br /> (�� con oouNim <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 8 0 o N <br /> �f. <br />