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Burnett County- Office of Zoning Administrator w m f o <br /> APPLICATION FOR — LAND USE — PERMITS F ' <br /> N <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <br /> CM <br /> 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 Wisconsin. 5 obi <br /> OWNE lease Print) -� yAgent <br /> / Contractor or Surveyor or n F <br /> o � m <br /> 64 <br /> �y1 '/- m <br /> %a77, -,//7�N FTRi/JAL J +QVC_ Address <br /> City State,Zip Code ,� City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: n �1 <br /> New Building Filling/Grading "' 11 <br /> Addition Moving p <br /> Sanitary — Camping Unit <br /> Privy Subdivision 0 <br /> N <br /> Structure Use: I' ° <br /> (family home/cabin, garage, addition, etc.) o 0 <br /> a <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, (),J <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. (�1 <br /> o <br /> D � w <br /> Z <br /> Or 1 <br /> U1 � <br /> 2 / <br /> < a <br /> 4i <br /> O <br /> J <br /> N 3 <br /> J N <br /> m a <br /> o o <br /> Dj �z <br /> Z <br /> Z <br /> p <br /> ^� o <br /> Z <br /> p <br /> m c �.mm ° acm <br /> LD. a� nm5ap <br /> 9 00, to <br /> o3 <br /> 01 <br /> Tn€ c [ m <br /> —o; t <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o ? m y <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) <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 <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the i i C11 <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 reasonable time for the purpose of inspection. <br /> :rt <br /> SIGN HERE <br /> (signs r of owner r ding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> n-1 <br /> .ONi v, Noo,ci�m <br /> OWNSHIP PERMITS MAY BE REQUIRED o o °0 0 o fmp <br /> oQU) <br /> j <br />