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Burnett County Office of Zoning Administrator ' £ o <br /> 2. <br /> APPLICATION FOR — LAND USE — PERMITS z3_ <br /> s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v w (� <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,Sanit tion Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the$tate of W'sconsin. hl tmore w y <br /> O <br /> c <br /> m <br /> OWNER(Please Print) ontractor or Surveyor or Agent19 n F <br /> 30c F �! Es7` {� Qad 0 367 d <br /> Address Address <br /> l�Au< ,v pn h _TTA '5 6 Qa)U'AC ii-u <br /> City,State,Zippode City,State,Zip Co <br /> /- ?i,- Ts-5- - Z2Z 0C2- 3 � D <br /> Telephone Telephone i <br /> Permit(s)Applied for: i <br /> Cl<) ` <br /> New Building Filling/Grading -I <br /> Addition — Moving v \ <br /> Sanitary Camping Unit <br /> Privy Subdivision , 0 <br /> Structure Use: � � PCP— 4- `F/�und P o <br /> (family home/cabin, garage, addition, etc.) Z o <br /> o c <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. - 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. n <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. S I _ <br /> o <br /> 3 o <br /> Z <br /> A o <br /> \ w <br /> co <br /> O <br /> N ` � <br /> n -141 r <br /> Z Q <br /> Z <br /> DoE (d <br /> 70 <br /> m C2.0 ma`- m�DDal <br /> • a� <br /> 0C.0 -a3 <br /> gi c C <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 `-�•'-E ` j m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) cx� <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the <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 /> mises at any reasonable time for the purpose of inspection. - <br /> SIGN HERE <br /> (s' a re of owner building contractor (Ilate) <br /> ` LJ o: o <br /> ZONING ADMINISTRATOR " m <br /> N N O J <br /> TNN TOO <br /> TOWNSHIP PERMITS M BEREQUIRED o 0 0 o c c fmq <br />