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Burnett County Office of Zoning Administrator w o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v i°n <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 o e State o Wisconsin. o <br /> m <br /> = m <br /> OWN E9IC,D�se ri ) / Contractor or Surveyor or Agent a Lf <br /> Address �—� ,, ( Address m <br /> City,State,Zip de City, State,Zip Code <br /> VLA/ 1110 y 1� )Yl N W <br /> Telephone ty v��4 Telephone ;11Vj <br /> Permit(s)Applied for: v`' <br /> New Building 4— Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o (D <br /> 0 <br /> Structure Use: 7Th�'/� ��� ° <br /> (family home/cabin, garage,addition,etc.) z <br /> o ° <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. or <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 /> Z <br /> �IU7_ PI o <br /> rn <br /> Uj <br /> 67- <br /> 1 � 0 <br /> ' 3 � � <br /> — o 0 <br /> I <br /> f\ <br /> ` N <br /> P <br /> O <br /> 2 <br /> / h� <br /> 0 a< JJOn-.m <br /> tn': � 0 p =f0 ; <br /> Z O: 50Q : : 1 <br /> 0 J En. <br /> ^i c : m <br /> 0 : <br /> : c C <br /> jo <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> o b <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- [ n': <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the a <br /> County of Burnett relying on this ipformation I(we)am(are)providing in this application. I(we)agree to permit county offi- <br /> cials charged minister' g unty ordinances or other authorized person to have access to the above described pre- P: I <br /> mises at anyTeasonab ti of the purpose of spection. ; ;..y? <br /> SIGN HERE <br /> (sig ur of own or buil ntractor) (dale) \' o <br /> 1 8 8 <br /> ZONING ADMINISTRATOR ' ' E <br /> HINT lT fNTO (NT <br /> TOWNSHIP PERMITS M BE REQUIRED 88888 <br />