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Burnett Bounty Office of Zoning Administrator m o o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> � o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -o w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0C <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- — <br /> ti�p�+s of the State gLwls nsin. m o <br /> l�K EFS E�I <br /> ` o <br /> O NER rPlease Print) , I //l� Contractor or Surveyor or Agent ajr) 0 <br /> jhJL <br /> �I <br /> A s Address m <br /> City,Skate,Zip Code' City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: I <br /> New Building Filling/Grading <br /> Addition Moving v <br /> Sanitary Camping Unit <br /> Privy Subdivision o' <br /> Structure Use: t �I"' IL� -iIVllli� l��.t/fn-Vyl ' 1 0 <br /> (family home/cabin, garage, addition, etc.) Z <br /> P <br /> v <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. O <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. (P <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by L1 <br /> the owner. <br /> o Ci <br /> 9 o_ <br /> �] Z <br /> A&a4 <br /> so <br /> Vv N <br /> _ c <br /> n_ <br /> 0 <br /> I <br /> O <br /> G (n <br /> O p <br /> \ 0 J <br /> q o <br /> � Z <br /> 1) 711 <br /> � <br /> w m o 3 <br /> cE m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of 0 : E m : S <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the i ; m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- f [>`: <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the :ac <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- ` `N <br /> mises at any reasonable time for the purpose of inspection. <br /> a :moi <br /> SIGN HERE �0 <br /> (signs o owner orb 'din on rector)_ (date) f o E [ [ <br /> o: o <br /> ZONING ADMINISTRATOR ycxi <br /> N N O, fN1, <br /> 6162 <br /> l WNSHIP PERMITS MAY B EQUIRED S <br />