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/ - I , <br /> Burnett County Office of Zoning Administrator cn v Z <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO TWE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <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- 3 n <br /> tions of the State of Wisconsin. 3, o <br /> �0 <br /> OWN R Please P int <br /> Contra or S eyor or Agen J <br /> j hl �'�iZYI �tS� -"-a <br /> Add�a T au 'l ! 7 1I V �" )IllL- Addres� . Q1QI X 'k � L_,J�1 J7]� RI`l11 1 I <br /> City,State,Zip Code City,State,Zip Code <br /> I <br /> Telephone Telephone �Q <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit T 0 <br /> o <br /> Privy Subdivision oJ' <- <br /> w r <br /> Structure Use: o <br /> J <br /> (family home/cabin, garage, addition, etc.) 0 0 <br /> a <br /> m <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). <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. o <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 /> 6-PLO�OpyA is egal description on the side of this form) as on tax statement. 03 <br /> 'P y <br /> Z Q <br /> O a <br /> N, <br /> Lp <br /> 0 <br /> IJ^ <br /> O IpNvr'1J1 <br /> J <br /> J <br /> O <br /> n <br /> T <br /> A <br /> Z <br /> O <br /> Z <br /> I j— <br /> �jl <br /> n o'< JJnp.—m <br /> m a� =am ^;nom <br /> < ' d <br /> co O J <br /> O O <br /> Ai m <br /> Cc <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m e c C <br /> PP f 9 Y 1 Y ll a <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that A <br /> PP (� 9 Y ) 9 � O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether toissue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing i [ <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ' <br /> person to have s to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE d' I <br /> gnat re of owner o ilding contractor) (date) : v N <br /> ZONING DMINISTRATO <br /> »T <br /> TOWNSHIP PERMITS MAY BE REQUIRED N o o m <br /> 0000000lmA <br />