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r�r', %101 C. <br /> Burnett County Office of Zoning Administrator ; - f o <br /> APPLICATION FOR — LAND USE — PERMITS z a <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 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. - <br /> tions the tatep of Wisconsjn. / _ w m <br /> m O <br /> OW01,R(Please Print) Contractor or Surveyor or Agent a f+) <br /> °i L <br /> KdresAddress g <br /> OWC ` es r k %&,. rs <br /> City,State,Zip ode City,State,Zip Code <br /> I -0 <br /> Telephone Telephone !� <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary _ Camping Unit <br /> 0 � <br /> Privy Subdivision 0 a <br /> ry�� 1 / N <br /> Structure Use: 31W/ y�/ DAL o <br /> (family home/cabin,garage,addition,etc.) o o Z <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 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 /> 3 <br /> a o <br /> Z <br /> 0 <br /> IQ <br /> 0 <br /> Ro <br /> 2. 0 ) <br /> CEJ o <br /> tf o � <br /> co <br /> r- <br /> p�R� o w s� <br /> Y Cu <br /> i <br /> 54 <br /> Z o <br /> 0 <br /> Z <br /> I� <br /> 9 Wn7mr DD W-0 <br /> M c M0 W 0 a c m <br /> m a� ''nm nag <br /> O N N O Z m 3 <br /> O : Ca <br /> Tn: 's 2 m <br /> 0 0 : 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 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 /> q � <br /> SIGN HERE '1-9L5 <br /> ( ' n ure of owner ing contractor) (date) o[ [ [ c <br /> ZONING ADMINISTRATO <br /> w-I <br /> 67 <br /> ��B.uNiooc�'iim <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8888888 in <br />