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�� C<. in � - <br /> Burnett County Office of Zoning Administrator ; - 0 o <br /> APPLICATION FOR — LAND USE — PERMITS g 2 ' <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 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 /> (i�ns of the State of Wiscon in. m m <br /> /�MARvjti �• MM,'D£��ti �- C <br /> o <br /> &J�i/NE (Please Print) p Contractor or Surveyor or Agent n <br /> �761, 4f1Kr,c�ti� U, ���7Qy w <br /> Address Address <br /> � � �� ` � <br /> City,Stat Zip Code City,State,Zip Code I I <br /> Telephone Telephone <br /> I <br /> Permit(s)Applied for: <br /> New Building Filling/Grading °q 1 <br /> Addition Moving a <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> N <br /> Structure Use: <br /> (family/home/ abin, garage,addition,etc.) o 0 <br /> a <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. U <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 /> N a o <br /> ./� It )r Q <br /> C r� <br /> CA <br /> c <br /> n <br /> N <br /> O <br /> N <br /> m <br /> m .O. <br /> i O p <br /> I � <br /> w o <br /> T <br /> 9 <br /> 7o rnvNr D Dmy <br /> m nc - nm �n� <br /> c w o S 3 <br /> 0 2moPm <br /> Z o: mZ : 1 <br /> o ' Co' <br /> S ^ i 2 ' : m <br /> u : 0 : O <br /> �0 € c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of —0 <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are)responsible for the i m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) 5qi I <br /> further declare that I(we)recognize that this information I (we)am(are)providing will be relied upon by the County of Bur- ;c i <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the fl <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 pre30 <br /> - <br /> mises at any reasonable time for the purpose of inspection. <br /> m E E 'moi <br /> SIGN HERE <br /> (si ure of owner or building contractor) (date) ' oo <br /> ZONING ADMINIS RATOR ° <br /> IVNOIV��NT <br /> N(T(T tTOONm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o g o 0 0 o trail <br />