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Burnett County Office of Zoning Administrator m -0o a <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> 0 <br /> TO THE ZOUI G ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur. m `m <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. m o <br /> 4i� �i �N cSA`iZ� a O <br /> OWNER(Please Print) Contractor or Surveyor or Agent o <br /> �y�3"7 l.oNlP �,lZ.rrL �D <br /> Address Address t <br /> 2QAf�JU/lfil <br /> City,State,Zip Code City,State,Zip Code t <br /> Telephone Telephone <br /> Permits)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o 1 <br /> Sanitary —, Camping Unit o <br /> Privy Subdivision m ' <br /> Structure Use: <br /> { 2uJ �ty2llinq -htlifs3(Zl <br /> (family hometcabin, gar e,addition,etc.) 0 0 <br /> a <br /> _ m <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). <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. Q <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 /> 0 <br /> PLOT PLAN <br /> a m <br /> c <br /> Z a <br /> o n4N^) <br /> L m <br /> �o <br /> r• � <br /> N - <br /> qJ' y m ' <br /> 1 <br /> 18 7C z <br /> rr• <br /> J � N N DD <br /> m c m a c <br /> T a� m ° <br /> T. < : m w <br /> N O =00 <br /> Oi Q <br /> N <br /> 0 [ A <br /> b <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 alln , : rn <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a Q oo <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 <br /> person to have acc to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> (sigg owner o co tractor) (date) <br /> ZONING ADMINISTRATOR o o <br /> T <br /> WNSHIP PERMITS MAY IiE REQUIRED <br /> oo� oo� <br /> �f <br />