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Burnett County Office of Zoning Administrator d M a ! o <br /> APPLICATION FOR — LAND USE — PERMITS d 3 0 _ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a ' <br /> tions of the State of Wisconsin. ^p <br /> N � <br /> J'l-!A./ ✓HL-Eiz o <br /> OWNER(Please Print) Contractor or Surveyor or Agent - !0E'o <br /> m <br /> Address Address <br /> 97Z{o s' /'A10K s 7— <br /> City,State,Zip Code City,State,Zip Code i <br /> izR tiro <br /> Telephone Q(�� ?( Telephone <br /> i <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition Moving g <br /> Sanitary Camping Unit n o <br /> Privy Subdivision 0 <br /> C1 r <br /> Structure Use: -'riU1 �' ( � I `^ f <br /> I, (family homelcabin, garage, addition,etc.) o o _ <br /> a l <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). 9 <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. <br /> n <br /> PLOT PLAN a legal description on the side of this form as on tax statement. 3 <br /> o n <br /> Z c <br /> o a <br /> N <br /> O <br /> I n) n <br /> V' <br /> X� <br /> O <br /> O <br /> 1 <br /> ll' <br /> m <br /> 0 <br /> �. <br /> T <br /> A <br /> �v Z <br /> Z <br /> cm.ddoaam <br /> U- _. <br /> n MOa <br /> m <br /> =am =am <br /> o <° cmo='3 <br /> N z w O J D <br /> Z O .2 1 <br /> in€ m <br /> o : € C) <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my -S: <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all .0 m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that A <br /> PP C 9 Y ) 9 v ': <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ' a <br /> person to have access to the above described premises at any r nable time for the purpose of inspection. <br /> T <br /> �i N <br /> SIGN HER <br /> (s' ura of ow off-building co ract r) (date) <br /> E of o <br /> ZONING ADMINISTRATOR <br /> 010 <br /> OWNSHIP PERMI MAY BE REQUIRED o N m <br /> O�N(T!T O O(T <br /> � 000000glA <br />