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Burnett bountyOffice of Zoning Administrator ; m o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> ns of the Stat�ef�Wisconsin. <br /> ti — <br /> 4/1 n >Ji%� P��Sc1„. W <br /> fER(Please Prinf Contractor or Surveyor or Agent n -f <br /> ' ID 0 X S`1 O <br /> d <br /> tress I Address <br /> f v Lo1(S' <br /> City,State,Zip Cod / City,State,Zip Code <br /> Te ephone Telephone ` A� <br /> O <br /> Permit(s)Applied for: i <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary _ Camping Unit <br /> Privy Subdivision o <br /> fStructure Use: �- 4 �.�' �- �Y"� 8 <br /> I (family ho /cabin,garage, addition,etc.) Z (7] <br /> o ° <br /> a <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. -- <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, 'ty <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 /> 0 <br /> p <br /> Z �1 <br /> O <br /> Zt- <br /> 4 C <br /> U c = <br /> Q <br /> �J a <br /> C n w <br /> co <br /> J1 <br /> of <br /> m' 0 <br /> 0 0 <br /> w <br /> Q <br /> 21 <br /> v� o <br /> —;� Z <br /> to <br /> cu'o <br /> n c< m <br /> m a < m ';a7o <br /> v = <br /> Z N i oz= <br /> P = : y: <br /> d[ € 2 m <br /> 0 : 0 <br /> o I c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to thebest of o I <br /> my(our) knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for the ' E 30m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ^' D <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 g <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 witt administering county ordinances or other authorized person to have access to the above described pre- <br /> i o <br /> mises at any reatonable Time for hep pose of inspection. � <br /> SIGN HERE <br /> (sig re of owner M building contract (date) <br /> Wo <br /> - o ) <br /> ZONING ADMINISTRATOR ) ( NlAi N-n <br /> fYl vt vt o o cn m <br /> TOWNSHIP PERMITS MAY BE REQUIRED 88 888(a <br /> � J <br />