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Burnett County Office of Zoning Administrator m M 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> w O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z N „ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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 /> ��5✓ Ii�IS(rm`in �dnl OF ( ranlf ��ti%1(P( ( �P� I� � K 1�1c�US��a ) o <br /> OWNER(Please Print) Contragtodor S rrveyor or Ag t � <br /> m <br /> ress Addres <br /> rani tf_q S� IO VIP�S P✓ �11Z 5�6� <br /> City,State,Zip Codel City, State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving v <br /> Sanitary Camping Unit o <br /> Privy Subdivision <br /> 0 <br /> 1 <br /> Structure Use: Z <br /> (family home/cabin, garage, addition,etc.) o <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). p <br /> 2. Show the location of the well (W) septic tank(ST), and drainfield(DF). 'fes <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 /> 6.PLOT PLAN a legaldescription on a side o is form) as on ax statement. 3 <br /> o q <br /> Z a <br /> r. <br /> . �h� t <br /> 1 r <br /> a <br /> � 0 <br /> o <br /> N 1 <br /> O <br /> J O <br /> n <br /> m �J <br /> io <br /> � Z <br /> 0 <br /> ) Z <br /> (/�vtnrDD W <br /> co 5'M <br /> m a" - nm ;aS <br /> N y O 5n <br /> N <br /> j XI1 <br /> d i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all A m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a �: c <br /> permit.I further accept all liability which may be a result of the Count of Burnett relying on this information I am providing <br /> P P Y Y Y Y� 9 P 9 <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> N <br /> SIGN HERE <br /> (si ature of owner or building contractor) (date) ov [ No <br /> ZONING ADMINISTRATOR <br /> o: o <br /> TOWNSHIP PERMITS MAY BE REQUIRED N m <br /> 0000000 <br /> 0000000fp <br />