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Burnett County Office of Zoning Administrator f o <br /> APPLICATION FOR — LAND USE — PERMITS o �. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y / --- <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> 3 n <br /> nett County Land Use Ordinanc ,Sanitation Code,and with all other applicable Count Ordinances and the laws and regula- <br /> y of the Stage of Wisc s <br /> OWN ER(Please Pant) C tr ctor or surveyor or Agent n - F <br /> tit 11 er _b <br /> Address Address <br /> I Ja+.. rid but -All IA-I.,4()C, -Ecf i <br /> y,St te,Zip Cod City,Stat ,Zip Code-77 <br /> 1, G <br /> Telephone Telephon <br /> Permit(s)Applied for: �/ J <br /> New Building "` Filling/Grading '1 <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision a <br /> �� Lib n anr� <br /> Structure use: 0 5 <br /> (family homelcabin, garage, a dition, etc.) z o <br /> o � <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. t3j 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. Jj <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 /> `tee 1�raw 3 s <br /> � yn <br /> Z <br /> U) <br /> 01 <br /> c <br /> n <br /> C� 5 s <br /> 0 <br /> I j <br /> �N <br /> m <br /> m c <br /> O <br /> m �'IIII�h_I <br /> UN I <br /> �0 <br /> Zr, ' <br /> 0 <br /> Z <br /> ]7 <br /> w `two fro _ <br /> Z o'E mZ ; i <br /> y: A <br /> M <br /> g <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of S; i im i A <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 /> data)] 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- E s✓` <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- E <br /> mises at any reasonable time for the purpose of inspection. m <br /> rn s-r. i <br /> SIGN HERE "i <br /> (si nature of owner building contractor) (date) �` o o <br /> ZONING ADMINISTRATOR ��'� - n (1 N o N <br /> N- u, oou�m <br /> TOWNSHIP PERMITS M Y BE REQUIRED $ 888y <br /> 1s, <br />