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Burnett County Office of Zoning Administrator (n0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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. <br /> N W n' <br /> A,e!/f Asrn�� <br /> 6 V <br /> C <br /> OWN Please P ' t a <br /> ( ) Contractor or Surveyor or Agent J <br /> ,2 <br /> Add r / Address <br /> Rzu/. <br /> City, SWde City,State,Zip Code <br /> V�-opo a� <br /> Telephone Telephone R <br /> Permit(s)Applied for: t 1 <br /> New Building Filling/Grading o <br /> Addition Moving p <br /> Sanitary Camping Unit O <br /> Privy Subdivision o o <br /> Structure Use: ° <br /> v <br /> (family hom /cabin,garag , addition, etc.) o 'o <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). Ch <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, Y/ <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 /> rove a ego escrrp ion on a side o is form) as on tax statement. O <br /> PLOT PLAN 9 <br /> a m <br /> z c <br /> o a <br /> N <br /> O <br /> I � <br /> aa <br /> a� 00 <br /> 0 N <br /> a� <br /> o � <br /> _o <br /> A <br /> CIO <br /> J Z <br /> O <br /> Z <br /> m c= r-n> <br /> accm <br /> n ac 0 <br /> LD. <br /> a� <br /> M <br /> o0 <br /> <a': o o 3 <br /> o 0 <br /> z o: <br /> _ to: � <br /> V n i i m <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my � <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuo <br /> racy of all ' m <br /> A m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that a p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <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 a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> (signal owner or bu' contractor) (date) <br /> o: o <br /> ZONING ADMINISTRATOR o o <br /> �-n <br /> TOWNSHIP PERMI MAY BE REQUIRED o o N m <br /> 0000000M <br />