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Burnett County Office of Zoning Administrator d a o <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and Q 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 i <br /> tions of the Staten.of'ism »_ <br /> �(lt�1L1QS Ufa (le J fi <br /> OWNER(Please int) I Cent r for r Sulyeyl r or Agent o O, <br /> Addrer) '��^� L�j', <br /> City,State,Zip Code City,State,Zip Code -' <br /> t. <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit c> <br /> o ) <br /> Privy Subdivision ,`,- c) <br /> y <br /> Structure Use: <br /> (family homelcabin,garage,addition, etc.) o o <br /> v <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. <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 /> 6. uVlue legal ip ion on trie side ot this orm as on tax s a emen o <br /> PLOT PLAN 3 <br /> a y <br /> Z Q <br /> o/ <br /> aC � o <br /> r—' <br /> a -P, 0 <br /> f <br /> r <br /> 0 <br /> m <br /> 0 <br /> N I (� <br /> O {hJ <br /> 0 <br /> m � <br /> n <br /> 7�0 0 <br /> � z <br /> I � <br /> � W V tnrDD W� <br /> m c �.mmnacm <br /> m arcRnmaM <br /> a °1cyo�3 <br /> �i m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that 1 am responsible for the detail and accuracy of all a: m <br /> information contained in this application(including an accompanyingschedule and I furtherdeclare that I recognize that <br /> PP ( 9 Y ) 9 '. m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a - Ao <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing ; ' i n <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 vw' <br /> N rty <br /> SIGN HERE <br /> (signature of owner or building contractor) (date) -�4 E E <br /> ZONING ADMINISTRATOR oo o <br /> s T <br /> TOWNSHIP PERMITS MAY BE REQUIRED o o m <br /> 00000 oo Cn <br />