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e9_7�n <br /> Burnett County Office of Zoning Administrator ; M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z UJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -p m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of thle Bur- 3n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and rbgula- <br /> tions of the State of Wisconsin. w m <br /> y�( r1II�_ rro��nl� m <br /> OWN (Please Pri Contractor or Surveyor or Agent n F <br /> Add ) Address :° 1 <br /> ibl <br /> W� <br /> J i <br /> City,Stat City,State,Zip Code <br /> Telephone Telephone <br /> I <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> Structure Use: Q �a�e �-+r (1ot;�`�/ 'L� //\ �' ° <br /> (family home/cabin, garage,addition,etc.) z <br /> o <br /> a <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). I .� 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. o <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building tc 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 del ad by <br /> the owner. <br /> -- o <br /> 3 o <br /> a� <br /> 4 <_ <br /> t N <br /> O <br /> o_ � <br /> /Y)�-r- y <br /> N <br /> 0 <br /> 5f ar�p <ShQ Te. 6e /acE��cl <br /> bo Pk` /7?/94 6&, I <br /> 21Z <br /> Z <br /> mvm D 03'D <br /> m c .mmo S.m <br /> m nom '-'nm EL <br /> o' dcy <br /> S. <br /> Z m <br /> 00 n <br /> 0 0 i m z 1 <br /> yi i 31 <br /> c m <br /> v : O <br /> 52 oI c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the bestof <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for it e m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (w ) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of BL r- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result oftI e <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county of i- <br /> cials charged with administering county ordgances or other authorized person to have access to the above described pr - <br /> mises at any reasonable time for the purp a of inspection. m <br /> _ m <br /> SIGN HER _X( - <br /> (sign o own or bui ontractor) (date) <br /> e of o <br /> ZONING ADMINISTRATOR - n <br /> �N Nm <br /> TOWNSHIP PERMITS Y BE REQUIRED oo$o oCA <br />