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Burnett County Office of Zoning Administrator wom o 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <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 'sco o <br /> Z.Y/IEGS �t/o�-7h <br /> OWNER(Please Print � 1 0 <br /> Contr/a�ctyo�r or Surveyor or Agent n 0 <br /> Address Address <br /> 36 <br /> City, State,Zip Code5' tt City, State,Zip Cod <br /> 'IIS_- <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit m <br /> Privy Subdivision <br /> m <br /> Structure Use: Mme— n <br /> (family home/cabin, garage,addition,etc.) Z d V <br /> O V <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 /> ,L,q Ke Z <br /> o � <br /> Ilk <br /> Q <br /> n <br /> 0 <br /> � o <br /> J <br /> N <br /> J N <br /> m <br /> 0 <br /> N J <br /> V W. <br /> T <br /> V• i. m <br /> Z <br /> r <br /> m c _.mwoac <br /> n v< JJnn-.m <br /> m n� nm »nom <br /> w'E zNii ��J3 <br /> J ' : Uo: W <br /> m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of 0 : f m <br /> my(our) knowledge and belief it is true, correct and complete. I(we)acknowledge that I (we)am(are)responsible for the ' <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) p <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- I c <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- 'a <br /> mises at any reasonable time for the purpose of inspection. m <br /> SIGN HERE �j/ ^ z "_'`� �/ O " d+ <br /> gn ure of owne ilding contractor) (date) <br /> [ 8S 8 <br /> ZONING ADMINISTRATOR ° <br /> IUNON� N <br /> N(T Ut Ut O <br /> TOWNSHIP PE ITS MAY BE REQUIRED 88008 8 <br />