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Burnett County Office of Zoning Administrator w 0 <br /> APPLICATION FOR — LAND USE — PERMITS <br /> z g <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 u <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 Wisconsin. <br /> Rf cK I3�Z�a 11 �J <br /> n 0 <br /> OWNER(Please Print) Contractor or Surveyor or Agent n F <br /> 369 C • M'46-NoLfIr- 4 <br /> Aress Address <br /> L4 L_ 114,,v AJ 5s/� , <br /> IC ty,State,Zip (/ City,State,Zip Code <br /> Gl 77(r S2,3st I(aG2 29L -5$�4� <br /> Telephone Telephone <br /> Permit(s)Applied for: n <br /> New Building Filling/Grading �-- <br /> Addition MovingUj <br /> 0 <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> �I <br /> Structure Use: CfF6,Aj 14bz)f 1 1O A.1 <br /> (family home/cabin, garage,addition,etc. Z <br /> P ° <br /> 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. o <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 /> o <br /> Z <br /> ° <br /> N <br /> q� Cr <br /> w <br /> I <br /> J <br /> of <br /> 3 N <br /> 0 <br /> m ° <br /> O p <br /> N J <br /> Ij t <br /> A <br /> IIIt•1�^� <br /> m 1 <br /> m <br /> Z <br /> O <br /> Z <br /> Sep ►`a <br /> mvrnr 0 <br /> `r '> > ona= m <br /> m a� am =y <br /> F. <br /> a' mcmo <br /> Z N � N ° J — <br /> Ji Cn <br /> m <br /> ° [ A <br /> 8 c <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 t'0 o E ?,�_ m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) E ; G <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 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- i i i i So E <br /> mises at any reasonable time for the purpose of inspection. - <br /> an <br /> SIGN HERELAIA4 -- <br /> (si ature of ownerA building contractor) (date) o E E 'moo <br /> �U1.J c: � o <br /> ADMINISTRATOR iJ N O N T <br /> !r!s!s v o m <br /> M <br /> TOWNSHIP PERMITS aAY BE REQUIRED SSSo S <br />