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C <br /> Burnett County Office of Zoning Administrator ' -0 o 0 <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> L_ <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 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 <br /> egula-tionssof the State of Wisc/opsin. A` a L m a IN <br /> OWNER(Please Print) Contractor or Surveyor or Agent n n f <br /> 3YoY ec/tf� :117 d3y is 2A m Ti <br /> Addr s A dress '? p <br /> �lt}Fre , /o✓S 5-Y-701 A- /m' 6✓S <br /> Cit State,Zip Code City,State,Z p Code <br /> �715�� 3' 3S—i93� 611 b 5 X56 , <br /> Telephone Telephone <br /> tR 1U <br /> Permit(s)Applied for: � <br /> New Building X Filling/Grading J <br /> Addition Moving �t <br /> 0 <br /> Sanitary Camping Unit <br /> Privy Subdivision fr'� <br /> Structure Use: Ae e 5fee1 (dQ � <br /> ONS ruc / rd� o'+j �s <br /> (family home/cabin, garage, addition,etc.) Z <br /> 0 ° <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). 41, <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, CA <br /> river or stream, if applicable. t <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by 7 <br /> the owner. r� <br /> o <br /> 16)0, 7gf GrrrN 4/�Ke 3 <br /> 0 <br /> FB) 2 A4 u� < <br /> m <br /> °C <br /> a <br /> S ;F <br /> s;(io' iF <br /> 4j <br /> Rai 0 <br /> (NS ) Ss m <br /> Z Z <br /> w o <br /> ]] 31s M <br /> AVV• � v` I^'IV� <br /> (} I (nv(nrDm <br /> n <br /> m <br /> o. <br /> m � ':o. <br /> v 0 . <br /> m" � m p <br /> N: . <br /> lu� 2iD <br /> 0 <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 j ` m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) j[ � G: : <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- j <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the _ c <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- ' `N <br /> mises at any reasonable time for the purpose of inspection. <br /> m <br /> z �" <br /> SIGN HERE <br /> (sign ure f owner or b <br /> 'y59Kng contractor) <br /> (date) <br /> ZONING ADMINISTRATOR � <br /> VNO U <br /> (TNfP(nOON <br /> TOWNSHIP PERMI S MAY BE REQUIRED 000000� <br />