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C=- 7 <br /> Burnett County Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS w 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and o <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n G <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 Wisconsin1 <br /> � l.l L <br /> c m <br /> 1dLOWNER� f(Plefase Print) ii O <br /> Contractor or Surveyor or Agent F <br /> m <br /> Ad reIss Address m <br /> ruJ 4 yct� LTs MN' SSl1> n -*Xz> <br /> City,State,Zip Code City, State,Zip Code t— <br /> H ` 1a • Vsy- Lo-21 1.) [ Ii. Lirl- s3;) <br /> Telephone Telephone �Q �— <br /> Permit(s)Applied for: CxQ O <br /> New Building X Filling/Grading _y <br /> Addition Moving <br /> Sanitary ..) <br /> Camping Unit <br /> Privy <br /> Subdivision 0 O <br /> � A <br /> w <br /> Structure Use: '41 ICS e 6 n L <br /> (family hometcabin,garage,addition,etc.) Z O <br /> o <br /> 9 <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. f" ^9�-- <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, e <br /> river or stream, if applicable. C <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by Z IR1 <br /> the owner. <br /> U <br /> �[ �'Le4R1'ny - Ha pki nS 5"cnd + ftevr/ 3 fv <br /> cemenr - jJic-K Sh4rr,,;/ rl/5- �'v/�- .fyri/ 5�f <br /> Gaopnmy _ Sr2Ljr ,_ � w <br /> -- --- _ - _ <br /> i <br /> / <br /> w [ w <br /> 7 <br /> N <br /> 0 <br /> o J <br /> 5 N <br /> �V m <br /> 0 0 <br /> ' � O <br /> U <br /> i J <br /> I <br /> Z <br /> P <br /> Z <br /> n <br /> ]1 U <br /> S <br /> Ilk— <br /> lowf yt e'l�cK a rnv(nrDDtA-0 <br /> nM <br /> o'i <br /> € m <br /> of � »I O <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 o` P ' <br /> detail and accuracy of all information contained in this application (including an accompanyingschedule and I (we) `tel m <br /> PP ( 9 Y ) ? p <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- 'c` <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the ' 'o <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 re as able time for the purpose of inspection. m <br /> o o <br /> (si t re of owner ilding contractor) (date) G o <br /> a o: o <br /> ZONING ADMINISTRATOR -n <br /> N�� o �m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o g o 0 0 o y <br /> M <br />