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Burnett County Office of Zoning Administrator ; m £ o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <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- x.11 <br /> tionsof the.State of isconsin. w m <br /> J%trTiy <br /> OWNER(Pleas Print) Contractor or Surveyor or Agent o. F <br /> Address Address `D <br /> City,State,Zip Code City,State,Zip Code <br /> baa- X79- 06©� 9J <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading ) <br /> Addition Moving v <br /> Sanitary - Camping Unit m <br /> n <br /> Privy Subdivision a <br /> Structure Use: <br /> On I U <br /> (fardily home/cabin!, garage, addition, etc.) Z o <br /> o a <br /> m <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. (1 <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 /> n � <br /> 0 <br /> v o <br /> Z <br /> o_ <br /> i <br /> co <br /> c <br /> c <br /> I <br /> � m <br /> � � m <br /> m n <br /> o � o <br /> m <br /> m <br /> Z <br /> O <br /> Z <br /> 9 <br /> or <br /> m c�mw�ac�� <br /> m n n A ';n70 <br /> Z w 2 O m <br /> ' m <br /> �;o : E D <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of 10. : . <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 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 <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 he purpo f inspec ion. m <br /> m <br /> SIGN HERE / r <br /> �': <br /> (Sigrofu of owner uilding contractor) (date) o o <br /> ZONING ADMINISTRATOR IV N O N +N m <br /> NVt NOO(n <br /> o$ 000 <br /> TOWNSHIP PERMITS MAY BE REQUIRED c4i trail <br /> �rt <br />