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Burnett County Office of Zoning Administrator 0 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 2. g f <br /> w ' <br /> z g <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -p m <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 /> tions of the State of Wisconsin. m o <br /> CYl,4X CfA�2� v�/ ,c )�r�7h����� v3..p✓LS 0 0 <br /> OWNER(Please Print) Contractor or Surveyor or Agent ii F <br /> / o s` viP L3AN DACE LA �'E o'3 kl 6, <br /> Addres Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone ` <br /> Permit(s)Applied for: V W <br /> New Building /` Filling/Grading _ <br /> Addition Moving <br /> o <br /> Sanitary Y, _ Camping Unit <br /> Privy Subdivision a <br /> A�w 1�(Vo I n d <br /> N <br /> Structure Use: I � ��I La(�-. o <br /> (family home/cabin, garage, addition, etc.) Z v <br /> o ° <br /> 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. <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. A <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by a <br /> the owner. <br /> o <br /> v a <br /> Z � <br /> O � <br /> 1 <br /> 9 z � <br /> n y <br /> Q <br /> � Do <br /> cS� tET—f'RC'r-f�1� `'�l� K I � �f2tti�(r • ^ � I " <br /> 70 <br /> �T <br /> ft i <br /> mo 11 <br /> Z <br /> mvmr>> <br /> m n� -o.m ani <br /> o w-� two �ro 3 <br /> Z O: <br /> c : m <br /> o: ci C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <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) p <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 the purpose of inspection. <br /> / `f � <br /> SIGN HERE <br /> (sig. re of owner build' contractor) (date) ' <br /> l/ /jQ J E $E E E <br /> ZONING ADMINISTRATOR � 7'a'a) �YLC4?A�it,/Il .J�yq-n..� <br /> TOWNSHIP PERMITS MAY BE REQUIRED oo <br />