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Gt1 C oCll <br /> Burnett County Office of Zoning Administrator CI 'VCD o z <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 'z m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3n <br /> tions of the State of Wisconsin. — (� <br /> o <br /> / N � <br /> -Oautd Grew e = m <br /> o <br /> OWNER(Plase Print Contractor or Surveyor or Agent o -Tale m <br /> Address Address <br /> OYl 0 <br /> a <br /> City,State,Zip Code City,State,Zip Code .i �` C <br /> I <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o 0 <br /> Sanitary K Camping Unit <br /> 0 <br /> Privy Subdivision 6 <br /> r <br /> 'Sf+:tletaselJsY— 8� d/�O C9r� �!�.��� '� 7 a'a 1 T L S e <br /> v <br /> (family homel abin,garage,addition,etc.) o 0 <br /> m <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). <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 submit<XbWp architact,e gineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. 0 ` yr,e W c <br /> o <br /> PLOT PLAN 3 <br /> a � <br /> Z Q <br /> P a <br /> o <br /> rn <br /> � ' Z <br /> 0 <br /> N <br /> O <br /> 0 <br /> O <br /> 41 � <br /> O <br /> po G <br /> � I z <br /> D <br /> F <br /> M N r D D a)-v <br /> m c m 0 n c m <br /> m n ' m nam <br /> Z 0 O O O <br /> j <br /> O m <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that c O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a c <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ' -0 <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> m <br /> SIGN HERE <br /> (signage ofowneror building contractor) (date) <br /> ZONING ADMINISTRATOR ! -y-//I <br /> n� <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o P m <br /> m <br /> of gi;$tn <br />