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- <br /> BOrnett County Office of Zoning Administrator ac ("Du $ o <br /> APPLICATION FOR — LAND USE — PERMITS z o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and - <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 /> tlonsyf a State of Wisconsin. w o <br /> 7 At <br /> OWNER(Please Print) —� Contractor or Surveyor or Agent <br /> m & <br /> m <br /> Ad res. �— Address = �' <br /> City,State,Zip Code ' City,State,Zip Code <br /> Telephon4e Telephone «� <br /> Permit(s)Applied for: <br /> New Building Filling/Grading (A <br /> Addition Moving o <br /> Sanitary Camping Unit e <br /> Privy Subdivision o <br /> Structure Use: <br /> (family hometcabin,garage,addition,etc.) Z 'o <br /> A v <br /> m <br /> 1. Show t71ans <br /> nd size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). o <br /> 2. Show tof the well (W), septic tank(ST), and drainfield(DF). 4--. <br /> 3. Shaw tof any lake or flowage-if within 1000 ft.and the location of any river or stream -if within 300 ft. o <br /> 4. Show din feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, <br /> river orpplicable. <br /> 5. If,separe submitted by an ar hitect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the ow . //��'C �✓�> �py.3� �// G <br /> O <br /> EE <br /> C <br /> ba <br /> le <br /> I-A <br /> m00 <br /> v o <br /> ��sPilo; � <br /> I '<v6ciC ,T <br /> NC M.W n a <br /> m a< m a .m <br /> O < N 3 <br /> N <br /> 21 rn <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ^. O <br /> further declare that I we recognize that this information I we am are providing will be relied upon b the Count of Bur- <br /> ( ) 9 O (are) 9 P Y Y <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the �Vh' <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 pre- <br /> mises at any reasonable time for the purpose of inspection. <br /> m [ <br /> SIGN HERE <br /> (sign of owner Vlauilding con tor) (date) c <br /> o: o <br /> ZONING ADMINISTRATOR « <br /> IVNOIJ��N� <br /> Vt Vt V•cT O O N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o000000vmi <br />