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b' ( f-,d , I( i <br /> Burnett County Office of Zoning Administrator ; m o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> Q to <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 n <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 Wisconsin. w m <br /> T}?PHAN DU&;C i"2',L J. _' ;RGUSON m <br /> m <br /> OWNER(Please Print) Contractor or Surveyor or Agent n f <br /> HCR58 BOX1022 CTY HCR59 BOX4280' ° m <br /> Address Address <br /> 54801 [1 5LP801 i <br /> City,Sta�tteZiode City,State,Zip Code <br /> V p C- 9q'0 715-635-7482 ) <br /> Telephone Telephone <br /> �. <br /> Permit(s)Applied for: <br /> New Building FillinglGrading <br /> Addition Moving o <br /> v slur i <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> m <br /> Structure Use: )DUYL : A rIT101 TO XL�TING H0 ':d g <br /> (family home/cabin, garage, addition,etc.) Z o <br /> o 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. rT <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 /> 0 <br /> a o <br /> Z <br /> ' ATTACIiD c <br /> Dj <br /> uc� <br /> Ch <br /> 9-) a <br /> w <br /> o <br /> 1C <br /> 0 <br /> m <br /> o c- <br /> 0 <br /> w � <br /> Z ly <br /> m V <br /> � Z <br /> M <br /> M rN-0CD r­>>W-0 <br /> Q > ; 0a` m <br /> m n nm s9 <br /> coo='3 <br /> Z v Amo �m <br /> m o: <br /> O <br /> o c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of _�:o <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) 0�. l m <br /> '�l 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- '• l <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the i i Ea i <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 ordinances or other authorized person to have access to the above described pre- 1 `.n <br /> mises at any reasonable time for the Wrpose of inspection. <br /> m i i i mom' <br /> SIGN HERE <br /> is ature of ner building contractor) - - - ' <br /> o: o <br /> ZONING ADMINISTRATOR _ ry iv o is N-n <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIREp <br />