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Cv(\ rr�rV, 0.° i'(L <br /> Burnett Cotisrty Office of Zoning Administrator I 0 f o <br /> APPLICATION FOR — LAND USE — PERMITS z C <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <br /> C <br /> as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. 0 mn <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 /> OWNER Please Print) Contractor or Surveyor or Agent °- 0 <br /> 41300+ pN m <br /> Address Address <br /> /n <br /> City, te,Zip.(a.nv�C7 <br /> ode City, State,Zip Code �v <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> Structure Use: ��+� •+ horn C " D YIX 3(igf T <br /> (family hometcabin,garage,addition,etc.) Z o �• <br /> o v <br /> _ m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)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 /> -t LgYf•glwr <br /> 0 7p <br /> L 3 o <br /> Z <br /> 0 <br /> 9 Lk <br /> c I� <br /> wk <br /> L_ <br /> VA-1 <br /> b _ o o <br /> b <br /> ��- Zo <br /> in <br /> y Z � <br /> 0 <br /> � Z <br /> rb edAL&-T P- Nv C1�s <br /> Or �U <br /> � mv(nr DDmy <br /> n c > > cmin= m <br /> m a� nm an70 <br /> N m� 00,Z0 <br /> Z o: : -4 <br /> p : <br /> y: i A <br /> «€ m <br /> c's <br /> m : E p <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of —o im <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) F 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- :o t <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the d <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- m <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. <br /> m :rt <br /> SIGN HERE �"�'��' 7-Z <br /> (sign e o owner or�byy�JR-g contractor) (date) r ' e e <br /> ZONING ADMINISTRATOR ��`� �z� - • ,` ° �` ' ' �++-t <br /> pVpiu�i�p. Pm <br /> TOWNSHIP PERMITS MAY BE REQUIRED 8888888(a <br />