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�d� (;ti11L1) <br /> Burnett Oranty Office of Zoning Administrator 0 m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 30 <br /> — <br /> s. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and a 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n r w _ <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - `tel <br /> tions of the State of Wiscon in. o <br /> OWNER(Please Print) / Contractor or Surveyor or Agent n E <br /> .qI/ r cC(Ag, <br /> Address VAddress m <br /> L07 <br /> Ci y.,/,Tate,Zip Code City,State,Zip Code 0 <br /> Telephone Telephone <br /> Permit(s)Applied for: V� <br /> New Building Filling/Grading _ <br /> Addition Moving V� v <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> y'/ N <br /> Structure Use: I r`F13� '� 67 <br /> -4 rti 5--� o i <br /> (family home/cabin,garage,addition,etc.) Z _ <br /> P ° <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. J <br /> 0 <br /> 1 0 <br /> Z n <br /> 0 <br /> tqo , <br /> O <br /> 0 <br /> qf <br /> Dom'` <br /> m <br /> G4 o <br /> aY� <br /> M mvro r»W-0 <br /> Q<> > 0 $`- m <br /> nm ';nM <br /> �0MQ <br /> Z N N p p <br /> m <br /> $ i c <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 m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- <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 reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> V: O <br /> ( i n of owner orb Id' g contractor) <br /> (date) <br /> Q i,} <br /> ZONING ADMINISTRATOR zz!f o: o <br /> (T tT f01, O N <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0 000 <br />