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Burnett County Office of Zoning Administrator 0 o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 0 <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- <br /> tions offL the State of Wisconsin.I i 1 o <br /> JUJfY LTOCYy)� e �S ! l <br /> O ER(Please Print) ontractor or Surveyor or Agent n F <br /> Ic c <br /> Addre Ll I <br /> V Address �? <br /> City,State,Zip Code City, State,Zip Code <br /> t <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving O <br /> Sanitary Camping Unit k. <br /> Privy Subdivision o <br /> J v <br /> Structure Use: I (o 44 o <br /> (family home/cabin, garage, addition, etc.) z 71 <br /> o a <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, <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 /> o ^� <br /> 0 <br /> ` o <br /> i <br /> a <br /> 1F4,0 b, s <br /> 0 O <br /> i N <br /> � m <br /> l ro <br /> 0 <br /> N_ J <br /> 21 <br /> Z <br /> 0 <br /> z <br /> DU <br /> I <br /> n Q<l - 0n-.m <br /> m n < nm »ay <br /> m m 0 '0 no 3 <br /> m_ � <br /> d 2 m <br /> cc { p <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o <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) ' 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 <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 /> (ipm=yre of owner orb l ' g contractor) (date) o o <br /> n o: <br /> ZONING ADMINISTRATOR IJ N O IU m <br /> U TN TO <br /> 0 0 0 0 0 <br /> TOWNSHIP PERMIT AY BE REQUIRED <br /> 0000o Ul <br />