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Burnett County Office of Zoning Administrator m f o <br /> APPLICATION FOR — LAND USE — PERMITS 3. ° <br /> ° c;9a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and - <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 Co <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 Wis opsin. <br /> l `Y �Q q, r A/ m <br /> OWNER(Please Print) Contractor or Surveyol or Agent a M F <br /> I dx o o l 3 I �-Tv Ne1-74 m L m <br /> Address Address g 1 <br /> D 9 `f To d N n - J moi\ <br /> City,State,Zip Code City,State,Zip Code 1 1 n - <br /> r <br /> Telephone Telephone uy <br /> Permit(s)Applied for: ab <br /> New Building —,2'� Fil(ing/Grading <br /> Addition Moving o k <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> w <br /> Structure Use: ° <br /> its home/cabin stage, addition,etc.) z o <br /> P a <br /> w <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 /> 0 <br /> 3 r <br /> o <br /> v <br /> . 0 <br /> Z <br /> i <br /> Ll <br /> M <br /> c <br /> 05 <br /> Q <br /> n <br /> w <br /> I' L <br /> i �hj o <br /> 0 <br /> � fd38 <br /> 1 <br /> 3 y � <br /> Z <br /> Z <br /> 0 <br /> Z <br /> 3) fn-0coD Dmy <br /> w M� =am may <br /> o' <<'' dcm o'�M <br /> Z w w o o m <br /> p <br /> ° <br /> 2 : m <br /> o : i O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of .0 <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are)responsible for the E 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- it <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the i imi <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 ordin cas or other authorized person to have access to the above described pre- ' `w: <br /> mises at any re onable t' a for the put os of inspection. m <br /> w [ <br /> SIGN HE <br /> (sign owne b g contractor) (date) ` 'oo <br /> $' o <br /> ZONING ADMINISTRATOR <br /> ' N. N OOfNIi <br /> TOWNSHIP PERMITS MAY BE REQUIRED o �� <br />