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an f <br /> Burnett County Office of Zoning Administrator U -- 0 <br /> APPLICATION FOR - LAND USE - PERMITS3_ <br /> w o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located eh shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. m o t <br /> C/4 REvcE o <br /> a <br /> OWNER(Please Pr nq Contractor or Surveyor or Agent o <br /> F'' <br /> Address Address <br /> 50 S T /;//-u/ M/tiN <br /> City,State,Zip Code City, State,Zip Code i (�J <br /> Telephone Telephone <br /> Permit(s)Applied for: !> <br /> New Building FillinglGrading C� <br /> Addition Moving o C� <br /> Sanitary Camping Unit 0 o <br /> Privy Subdivision -`-' <br /> Structure Use: <br /> (f Z ily home/cab ga age,addition, etc.) o � <br /> Directions for plot plan drawing: Cj <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). 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. ,or, <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, ED <br /> river or stream, if applicable. 1 <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 /> n <br /> rove a ega description on a side o is form) as on tax statement. O <br /> PLOT PLAN <br /> v <br /> c <br /> Z P <br /> o a <br /> J U m <br /> o' <br /> i J <br /> t <br /> \J <br /> N <br /> J <br /> 0 <br /> N _ <br /> �� m <br /> Z <br /> O <br /> O <br /> / Z <br /> 1� � IVI�/1 3�7jry1 <br /> V� <br /> l� <br /> 71 N N D D W� <br /> N cid OaCm <br /> e o ago n a— <br /> MD. <br /> ate » M ';am <br /> N O J b <br /> m <br /> C-) <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 I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that n ` ! O <br /> PP ( 9 Y ) t of <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 p <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (sigRMf re of owner building contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> w-n <br /> - IJNOIV��Nm <br /> /TOWNSHIP PERMITS MAY BE REQUIRED u, o u,m <br /> 0000000 <br /> 000 0000lA <br />