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Burnett V�-mty Office of Zoning Administrator ; 0 f <br /> APPLICATION FOR — LAND USE — PERMITS 3_ <br /> y <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and - <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 <br /> /C'l n <br /> nett County land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> do sof the State of Wiscon m m ^ <br /> c Ca n ^ ;�9ppt, i� s <br /> m 7 <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> N w Z. <br /> A t]rgg�y Address <br /> City, Stgte,Zip Code 1 I city, State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> Sanitary _ — Camping Unit 0 Q\ <br /> Privy Subdivision <br /> V i V <br /> Structure Use: � <br /> if mily home/cabin, garage, addition, etc.) o o (� <br /> m � 1 <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, w <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 W <br /> 3 r <br /> 0 0 <br /> Z <br /> W <br /> Cn <br /> C <br /> n <br /> < s <br /> w /� <br /> Ei <br /> N <br /> O <br /> � N <br /> 3 m <br /> �p A <br /> v o <br /> N � <br /> T / <br /> O <br /> m c� oNim Da <br /> o'mm <br /> < > > 0 a= <br /> W om�3 <br /> rn � Z) O <br /> Cn <br /> ' € cc mO <br /> c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best o�� <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am (are)responsible for the = [n I m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <br /> further declare that I (we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur-`�1 E :a ; <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- p11-�' Em[ <br /> cials charged with administering county ordinances or other authorized person to have access to the above described--- io <br /> : <br /> mises at any reasonable time for the purpose of inspection. ` . ?rt <br /> : <br /> SIGN HERE <br /> (sig of owner or b 'Idigg c ntractor) (date) E o E E o <br /> ZONING ADMINISTRATOR a ru o N m <br /> P- v,- o o<n m <br /> NSHIP PERMITS MAY BE REQUIRED 8 y <br />