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Burnett County Office of Zoning Administrator m Li o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m <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- <br /> tions of the State of Wisconsin. 3. ` <br /> N � I <br /> Le)cctz �./C�cG%C � esfe►-S m <br /> O <br /> Oea a Print) Con actor or Surveyor or Agent o- £ <br /> WNER(Pl <br /> Addre s A ress " ��l� <br /> l r G . 47 <br /> City,Sta e,ZipCode City,State,Zip Code ' <br /> �*:-1 i <br /> Telephone Telephone ) <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p ('1j <br /> Sanitary Camping Unit <br /> 0 <br /> Privy Subdivision 0 �- <br /> Structure Use: <br /> v <br /> ,j (family homelcabin, garage,addition,etc.) o a <br /> Directions for plot plan drawing: a <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. 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. <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 /> LO PLAN a legaldescription on a side o is form as on tax statement. 3 Z <br /> 'P N <br /> Z c <br /> a <br /> o a <br /> w <br /> O _ <br /> I <br /> a <br /> 0 <br /> C� m <br /> m <br /> O <br /> o <br /> O <br /> Z <br /> m IryNy�.. <br /> Z <br /> O <br /> I Z <br /> Nc j m m o a cm m <br /> m cr< oono.—m <br /> m <br /> =am =am <br /> co 6 <br /> oi <br /> D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my c C <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 furtherdeclare that I recognize that � A E <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a 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 <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 /> �j m <br /> SIGN HERE <br /> (sig a of her or lding con actor) (date) 4 <br /> ZONING ADMINISTRATOR <br /> T <br /> J N O J <br /> OW <br /> NSHIP PERMITS MAY B REQUIRED u v v v o � <br /> 00000 <br />