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Burnett County Office of Zoning Administrator ( m f o <br /> APPLICATION FOR — LAND USE — PERMITS 3. ' <br /> z o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 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 <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tion of State of Wisgonsin <br /> k1 In <br /> OW,P1ER( leWPint') ._ Contractor or Surveyor or Agent n f <br /> m <br /> Ad ss Address <br /> M <br /> City,StM6,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading coc <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o' <br /> N <br /> Structure Use: O <br /> (family home/cabin, garage, addition, etc.) z <br /> o <br /> v <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. r <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 /> O <br /> 0 <br /> 9 ^C I 1 <br /> 2oorL <br /> W <br /> N <br /> 1, O <br /> N J <br /> G <br /> N <br /> O <br /> O N <br /> 0 <br /> ID A <br /> 2 0 <br /> m � <br /> .70 <br /> ( m <br /> m <br /> Z <br /> 0 <br /> Z <br /> D <br /> � mvNrDDWy <br /> a <� 91cioo='3 <br /> z o: <br /> �[ m <br /> o c 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) <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- 'N' <br /> mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (sig/\ng(�uurr�e of owner or uildiiinn7-gcoontract�o-r)) /1 (date) . . . ` <br /> ZONING ADMINISTRATOR -i <br /> N N O J N m <br /> JiNN(TfNOOUt <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 0 o um <br />