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(I'(\ CC)O-�-C - <br /> Burnett County Office of Zoning Administrator d -. 0 <br /> APPLICATION FOR — LAND USE — PERMITS3. <br /> d o <br /> TO THE ZaNING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <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- 3 a <br /> tions of the State of Wisconsin. :Z <br /> _ N d <br /> OWNER Please Print _ Contractor or Surveyor or Agent n f <br /> Addr s . Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone �— <br /> Permit(s)Applied for: <br /> New Building Filling/Grading 1 <br /> Addition Moving o <br /> Sanitary _ _ Camping Unit n o <br /> Privy Subdivision <br /> Structure Use: ..,Ai�7i.4 01431 - `w'Invl�- v w <br /> (family ho (cabin, garage,addition,etc o c <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. <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 /> 6. Pruvtdu terjut description (un the side of this FuLno) os a tax state e b. O <br /> O <br /> PLOT PLAN 3 <br /> D (rJ <br /> C <br /> Z a <br /> o n <br /> N <br /> O <br /> t J <br /> I <br /> 0* <br /> o <br /> O <br /> 2. IIIIII�J\ <br /> 2. U I <br /> O v l <br /> o � � <br /> (' <br /> r. Z <br /> O <br /> '1 z <br /> "1 <br /> m cm n as cmc <br /> Cr Maam <br /> 0 5-C <br /> N O 7 p <br /> m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my Z o <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 a O <br /> this information I am providing.will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> o : <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing w : <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> D E <br /> SIGN HERE <br /> ( �si natu a of ownerr r 6Q din o acto`� (date <br /> Amm lT, f L- flN'66 1 <br /> ZONING ADMINISTRATOR > o o <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED ^ ^ o^ ^ m <br /> NNv,�oo�m <br /> 0000000 <br /> 0000000dl <br />