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oil C <br /> Burnett County Office of Zoning Administrator m 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 v 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. 3 Co �J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tion of the State of Wisconsin. N m A <br /> -��N �l <br /> a O <br /> OWNER(Please Print Contractor or Surveyor or Agent ,( f <br /> Q uo u�•r mont+'eyrll� d <br /> Address Address `? <br /> La t Ek MA It, <br /> City, State,Zip Code City,State,Zip Code <br /> Telephone Telephone CiC. <br /> Permit(s)Applied for: <br /> New Building Filling/Grading V <br /> Addition Moving O <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> Structure Use: I�IAJ tri i I i �f l o <br /> (family home/cabin, garage, addition, etc.) 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, <br /> river or stream, if applicable. Oj <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. CK <br /> 0 <br /> 0 <br /> 3 r <br /> v o <br /> Z <br /> 4 C^ a <br /> CIO <br /> s <br /> f J I r 1 I V1 <br /> i E <br /> of <br /> 0 <br /> � o 0 <br /> Z <br /> Z <br /> (nvpirDDmy <br /> n v n m <br /> m n� 'nm aa>, <br /> a LA'.i mo0o' 3 <br /> O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o m C <br /> my(our) knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the = n m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- i i Et7 <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the ` ?a <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- lm i <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reasonable time for the purpose of inspection. <br /> m Err: <br /> SIGN HERE RAZ, <br /> (si re of own building contractor) (date) <br /> 0 0 <br /> ZONING ADMINISTRATOR Y N N N-n <br /> u o' m <br /> TOWNSHIP PE MITS MAY BE REQUIRED o 0 0 0 o vmi <br />