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Burnett County Office of Zoning Administrator 0 A F o <br /> APPLICATION FOR - LAND USE - PERMITS 3 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'a 00 ^ \ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - (^ <br /> tions 99f the State of,pWisconsin. <br /> Wt {�14r« /l t�1Y�I�MaR1Z Pe r- /T m o <br /> m O <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> 13os- f7ort31- RoL <br /> Address T a Address <br /> n 7- <br /> —� <br /> CLO e A A 0n� -4. S a U o 3 <br /> City,State,Zip Code City,State,Zip Code <br /> 3iq- ass - �9N1 <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading r <br /> Addition Moving 0 4 <br /> Sanitary Camping Unit ' <br /> Privy Subdivision 0 <br /> w <br /> 0 <br /> Structure Use: l- '> �L <br /> (family homeicabin, garage,addition,etc.) o <br /> a <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 ftr- <br /> 4. <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. r <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. h <br /> 0 <br /> 0 <br /> 'R �" 0 <br /> O IY » <br /> P <br /> N m <br /> 1 a <br /> w' <br /> J o <br /> �y 0 <br /> o u <br /> 0 N <br /> m � n <br /> 0 0 <br /> w ` 0 <br /> � ' V <br /> ti <br /> m <br /> m' <br /> Z <br /> 0 <br /> L ` <br /> I� <br /> 33 Cl)-o(n�DDm� <br /> 0 00.m 00-c m <br /> 0 n� �'am aaS <br /> o "00eo�3 <br /> o f i Z i 1 <br /> :I E m <br /> r7 8 i <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of g: m' <br /> my(ouo knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for the [ MM <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) I 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- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the ; 51 <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 /> C I 0 <br /> SIGN HERE <br /> o; <br /> (si ur of owner or bu' contractor) (date) [ o E [ i o <br /> ZONING ADMINISTRATOR (�ry�yro o N m <br /> NO T OON <br /> TOWNSHIP PERMITS AY BE REQUIRED 888rn <br /> J <br />