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Burnett County Office of Zoning Administrator 03f o <br /> APPLICATION FOR — LAND USE — PERMITS z o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 $ 0 <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 Wisc nsin- —� m �. <br /> r 9 C'�Df c <br /> I\ 1C'��(�1 c3��Ir�t1111 L m O <br /> OWNER Please Print/v ��yy Co tractor S eyor or Agent 4-- <br /> '�G N . �_ <br /> m <br /> Address �^ Ad�re$s <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone (-1 <br /> Permit(s)Applied for: N <br /> New Building Filling/Grading <br /> Addition Moving 0 <br /> Sanitary Camping Unit <br /> PrivySubdivision 0 <br /> m <br /> 0 <br /> Structure Use: v <br /> (family home/cabin,garage,addition,etc.) o 'o <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. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by P <br /> the owner. <br /> O <br /> 0 <br /> 3 r <br /> a o <br /> Z <br /> "P, j, <br /> o <br /> N , <br /> j L <br /> m <br /> o a <br /> Z <br /> �7 <br /> m <br /> Z <br /> f <br /> i <br /> �, € 2i m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> m ou knowledge and belief it is true,correct and complete. I(we)acknowledge that I we am are responsible for the `�-' <br /> Y( � 9 P ( 9 ( ) (are) Po E � E m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) i ' '• O <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 ECF <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- W <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- p: E <br /> mises at any reasonable time for the purpose of inspection. <br /> w <br /> SIGN HERE - <br /> (sure of owner or b -din cRntractor) (date) $ ' : o <br /> o <br /> ZONING ADMINISTRATOR <br /> rnv,u,<noocnm <br /> / OWNSHIP PERMITS MAY BE REQUIRED �8888000rn <br />