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• j _ <br /> Burnett County Office of Zoning Administrator M T 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m io <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 0. <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> tionyof the State of Wi consin. m o <br /> OWNER(Please Print) Contracto(or Surveyor or Agent n _ F <br /> ! � SO. - o <br /> m <br /> A ")`• ��Loo/ Address �? <br /> City,State,21pbo 7 City, State,Zip Code <br /> Telephone Telephone I <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o (__ <br /> Sanitary Camping Unit m _1 <br /> Privy Subdivision o <br /> N <br /> Structure Use: GA.eifbcr fold, firm . 8 <br /> (family home/cabin, garage, addition, etc.) z v <br /> 0 0 <br /> v <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. <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 /> b 9 <br /> Z <br /> W �J <br /> w <br /> = <br /> N <br /> 26' �D D m <br /> w � <br /> 1 <br /> Fial4 I <br /> ( m <br /> Z <br /> 0 <br /> z <br /> V m cM.wm <br /> n v< o 0 o a-.m <br /> v n� mcmo�; <br /> __—-__ w ? o ❑m <br /> : u)i <br /> a: E c' � O <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 1 m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- p <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- <br /> mises at any reaso ble time for the purpose of inspection. <br /> i+ <br /> SIGN HERE N• Dom[ ` /� P� ` E ? ! N <br /> (s' Lure of owner cy bui_in contractor) 1 (date) �' i o ' o <br /> ZONING ADMINISTRATOR - <br /> m <br /> TOWNSHIP PERMITS MAY E REQUIRED v o08o Vi <br />