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i' <br /> Bumett County Office of Zoning Administrator m f 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z s <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 of the State of Wisco/nsin. ,. m <br /> Lr l w m <br /> gvrN D Ty ° <br /> m <br /> OWNER Please Print) Contractor or Survey r or Agent n <br /> dress Address <br /> A i 1-eVO Uti -1-T72Y <br /> Ci tate,Zip Code <br /> (y— <br /> City,State,Zip Code <br /> i � <br /> Telephone Telephone V`� 6 S <br /> 1 <br /> Permit(s)Applied for. (7� <br /> New Building _ Filling/Grading <br /> Addition Moving O <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> Structure Use: C + SNI II lee' 0 <br /> (family homercabi ,garage,addition,etc.) o 0 <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 /> 0 <br /> 0 <br /> 3 <br /> 'R O <br /> 2 <br /> O <br /> I <br /> i a <br /> w <br /> 0 <br /> o <br /> 0 m <br /> m � n <br /> O p <br /> w � � <br /> 0� <br /> v � p <br /> a <br /> 0 a f Sfru�'u \. Cn-u <br /> 70 CM.a< to M 0 0 o0a a-� <br /> c <br /> 00 aCM <br /> m <br /> 0 <br /> rn <br /> 1,j8 ': ic <br /> I(we)declare the lication(including any accompanying schedule)has been examined by me(us)an 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. m <br /> m <br /> SIGN HERE 6j: <br /> ` <br /> ( ' a ure of owner or (ding contractor) (date) oo o <br /> o: g <br /> ZONINGADMINISTRATOR I : : En-n <br /> n"NNNoo"m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o000000vmi <br />