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Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v in <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of yta Bur- 3 0. <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applic ble County Ordinances a slaws avn(q'regula- <br /> t,06" <br /> o o the St to of Wisconsin. o <br /> ce oY �e �� GZ CJ l� m <br /> O (Please Print) Ce r ct r or Surveyor o gent n <br /> y O F <br /> 6� �an of i'VC �� � <br /> Ad ss A ress / '? <br /> 3 <br /> City,State,Zip Code City t to Zip C <br /> 3 <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit m <br /> M <br /> Privy Subdivision o <br /> `' w <br /> Structure Use: I ( Q o <br /> 71 <br /> (family homelcabin, garage, addition, etc.) Z <br /> p O F <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. r <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. fi <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 _ I <br /> v 0 <br /> z <br /> CA <br /> 0 <br /> 7 <br /> N <br /> O n <br /> ILI N <br /> C ' <br /> p R <br /> N <br /> m S 0 <br /> Z O <br /> TU n• � <br /> V <br /> E. <br /> 70 mvf/irDDmy <br /> inI € gym <br /> u,: <br /> 1 application(including Yaccompanying ) y ( ) g' C <br /> I(we declare that this a lication includin an schedule has been examined b me us and to the best of o M <br /> my(our)knowledge and belief it is true, correct and complete. 1(we)acknowledge that I (we)am(are) responsible for the i i 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- �; s <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the ?d <br /> County of Burnett relying on this information I(we)am(are)providing in this application. I(we)agree to permit county offi- :a <br /> cials charged with administerin aunty inan s or other authorized person to have access to the above described pre- ' `NI <br /> mises at any reasonable time r the rpose inspectio / m ': +n'• <br /> m <br /> AlSIGN HERE L _• <br /> (si tur of o ner o Iding co traacctor) (d te) E o' F> <br /> ZONING ADMINISTRATOR -VC��J".�1 ` ' �- ': g-n <br /> N V N <br /> WNSHIP PERMITS MAY BE REQUIRED o 0000fmA <br />