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Burnett County Office of Zoning Administrator ; ' i3 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 -U <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 C W <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 Wisconsin. <br /> c ;? <br /> a <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> Address Address m <br /> lg3c1 <br /> City,State,Zip Code City, State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> � m <br /> W I' <br /> Structure Use: ) S <br /> (family home/cabin,garage,addition,4c.) Z <br /> 0 0 <br /> _ 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. (� <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, !J <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 /> 0 <br /> 'R o <br /> z <br /> 0 <br /> C <br /> v <br /> a <br /> O L) <br /> � a m <br /> n » <br /> O V p <br /> DwGLr�" <br /> rM1 i 'm <br /> Z <br /> 0 <br /> r <br /> My r D <br /> m c m m n C <br /> a _ H o_ <br /> N <br /> oz <br /> Z0 <br /> O <br /> Ol7 <br /> i(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are)responsible for the f = m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) �j <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 theY :Q <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- 'Ni ' <br /> mises at any reasonable time for the purpose of inspection. <br /> -IGN HERE <br /> (si na,,ture of ow r building con or) (date) <br /> g : o <br /> ADMINISTRATOR : tn-n <br /> lJNOIV�+N <br /> N(T�N OONm <br /> TOWNSHIP PERMI S MAY BE REQUIRED o000000tmil <br />