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6n _ <br /> Burnett County Office of Zoning Administrator c o o <br /> APPLICATION FOR — LAND USE — PERMITS 3 F <br /> � o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Q m m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 a <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions - <br /> tions of the State of Wiscgnsin. » <br /> J�'f2orn�- l=F, <br /> OWNE�r #'R(PleI (Sase PrinuuBx Contractor Or Surveyor or Agent o. F <br /> Address Address m �' <br /> isoat_i- L.g*ce- G/l• 548 9/ <br /> City,State,Zip Code City,State,Zip Code \ , <br /> 4&u-43(.4- L <br /> Telephone Telephone -\ r"I <br /> Permit(s)Applied for: GVC�\ll <br /> O <br /> New Building Filling/Grading <br /> Addition Moving (� <br /> Sanitaryo <br /> Camping Unit <br /> Privy Subdivision o <br /> N <br /> Structure Use: <br /> (family home/cabin, garage,addition,etc.) Z <br /> 0 0 <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). < <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. 1­ <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 /> o <br /> a <br /> 2 <br /> O <br /> Y <br /> e <br /> Or <br /> 1 w <br /> t © to <br /> 1`14 Cn ' <br /> COAL Q Fa & <br /> e M w <br /> k F <br /> ' z <br /> p <br /> Z <br /> a <br /> 7 <br /> _un ell l" <br /> QWI.. <br /> m c�mmnnc�� <br /> m ado---nm nn� <br /> 24Y-d �., hle`ti! I�V If.t,71N �, o z° p1cwo='; <br /> � 5D q <br /> iAt2gGg) ° _ s A <br /> 2 : m <br /> 1(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of �' C <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for the o ' m rn <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) Jv' ,, t3 <br /> further declare that 1(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 :F, <br /> County of Burnett relying on this information I we am are providing <br /> ( 1 (are)P gin this application.I access <br /> agree to permit county pre- <br /> miseals charged with administering county ordinances or other authorized person to have access to the above described pre- y <br /> mises at any reasonable time for the purpose of inspection. m p; <br /> SIGN HERE Ot — 99 ? N <br /> Q (si a of own building contractor) <br /> (date) o: o <br /> ZONING ADMINISTRATORwri <br /> /!'9 �j4•fiy�� ° ': i E o <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 o S <br />