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Burnett,(3ountt Office of Zoning Administrator m o <br /> APPLICATION FOR — LAND USE — PERMITS3. ' <br /> z s � <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 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. <br /> ti s qT�_ f the State of Wisconsin. — <br /> l N � <br /> OWNER(PIe a Print) Contractor or Surveyor or Agent n f <br /> QR 3 rsL s� <br /> Address Address fD <br /> tate �sr (w 1 1 . S q �� <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: 1 <br /> New Building Filling/Grading �" <br /> 011) <br /> DIN <br /> Addition Moving E.o <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> Structure Use: o <br /> family home/cabin, garage, addition,etc.) Z o <br /> o <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. 41 <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. l},} <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by 44 <br /> the owner. <br /> 3 <br /> 3 0 <br /> a o <br /> Z <br /> LA <br /> O <br /> N I� <br /> c <br /> O n <br /> 1 5 <br /> O H <br /> o I_ <br /> J I�I}v},13 <br /> I <br /> 00 <br /> J VA <br /> N <br /> f0 A <br /> v o <br /> N J <br /> w <br /> O I� <br /> Z <br /> O <br /> Z <br /> I a <br /> MN o1 DDco-0 <br /> M <br /> ate' ma= m <br /> ,;ate <br /> D < <br /> A O J m <br /> Z <br /> y i i <br /> �� �✓'� � C <br /> (we)d are the is application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(o knowl a 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 a <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 /> SIGN HERE <br /> nature of ow r or building contra tor) (date o[ 1 0 <br /> ZONING ADMINISTRATOR - " .»-I <br /> 71 NN ooam <br /> TOWNSHIP PERMITS MAY BE REQUIRED 88 oeee(A <br />