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Burnett County Office of Zoning Administrator 0 f o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z21s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -o 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- - r <br /> tion,s,of the State of Wisconsin. w m <br /> Kebe � T CW'fVIto <br /> w H <br /> OWNER(Please Print) Contractor or Surveyor or Agent o. � �o <br /> $rro e <br /> Address Address <br /> M p l.r M <br /> City,State,Zip Code City,State,Zip Code Stj <br /> I IT <br /> Telephone Telephone <br /> 7 <br /> Permit(s)Applied for: <br /> New Building Filling/Grading n. <br /> Addition Moving 0 <br /> Sanitary Camping Unit fi <br /> c <br /> Privy Subdivision 0 <br /> Structure Use: <br /> (fa ly home/cabin,garage,addition,etc.) o 0 <br /> 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. <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, �W,i;� <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 /> c� <br /> 0 <br /> 3 � <br /> a o <br /> Z <br /> O <br /> r I� <br /> t n <br /> r <br /> w <br /> J <br /> o F <br /> J <br /> io <br /> m ° <br /> 0 0 <br /> J <br /> l� <br /> Z <br /> be 0 <br /> P /� t 9�� y Z w O J i0 RtUICAd `�J s I � � Irl/ -_I{1-'3{— ° <br /> In <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I (we)am(are) responsible for the 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- p <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the n: <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- ' <br /> A: <br /> mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (si tur of owner 'ding contractor) (date) o[ [ o <br /> ZONING ADMINISTRATOR <br /> U O O U O O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED 880088086) <br />