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Burnett County Office of Zoning Administrator C 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as 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- 3 a p <br /> tion!A the State of Wisconsin. <br /> N C1 <br /> N <br /> ` <br /> o <br /> OWNER(Please Print) Contractor or Surveyor or Agent o r� <br /> � C. '� o d l <br /> Address Address ` <br /> t .,� 6rT1� S 4593 <br /> City, State,Zip Code City,State,Zip Code <br /> Ci <br /> Telephone Telephone yJ <br /> Permit(s)Applied for: Q <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit o <br /> Privy Subdivision 0 .`.- <br /> C� o <br /> Structure Use: <br /> (family homelcabin, garage,addition,etc.) o 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. Q-- o <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. 41 <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. 1 <br /> 6PL&TrftvAVe legal description on the side of this farm) as on tax statement. O tq <br /> 'R AR` <br /> Z c— <br /> 011n7C <br /> O <br /> LA <br /> r N <br /> 6 9 » <br /> o r lV <br /> ro 'I <br /> o <br /> � L z <br /> M c�m maa aim <br /> n Q< m <br /> m n� —nm ^;ate <br /> a <' d00o53 <br /> N � N O J� <br /> Z O <br /> Ot <br /> L <br /> U): : m <br /> [ <br /> o[ is 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 accuracy of all �,^ n IT <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <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 a <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> p N <br /> SIGN HEREn � <br /> (sig lure of owner or building contractor) (date) <br /> o: o <br /> ZONING ADMINISTRATOR �- ` <br /> �-n <br /> TOWNSHIP PERMITS MAY BE REQUIRED N m <br /> c) c> $M <br />