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Bulmett Coamty Office of Zoning Administrator C f o <br /> APPLICATION FOR LAND USE PERMITSw 3. _ <br /> a _ o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -0 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 <br /> }-of the Stateof Wisconsin. <br /> /YJo < ��/L/C �A Lc/ S IIC m m <br /> OWNER(Please Print) Contractor or Surveyor or Agent o. F <br /> AddressAddress m <br /> .0, fCl <br /> City,State,Zip Code City,State,Zip Code <br /> ,91� - 777 - � 3a � 0_� <br /> Telephone Telephone , <br /> Permit(s)Applied for. C) <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit _ <br /> Privy Subdivision o <br /> _ <br /> N <br /> Structure Use: <br /> (family home/cabin, garage,addition,etc.) z a <br /> o ° <br /> a <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. 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. N <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 /> 0 <br /> 0 <br /> 3 o <br /> Z <br /> s e e 147414-cls <br /> c <br /> U1 n <br /> I = e <br /> o C w <br /> tN 3 <br /> o r . <br /> = N <br /> m <br /> m � <br /> O ^^ 0 <br /> Gr/ m c <br /> Z <br /> 0 <br /> z <br /> U D <br /> tti <br /> a rp�Nr DDmy <br /> m n� nm a'n9 <br /> w'E Zw$ �m= 3 <br /> Z o; m•2 ; 1 <br /> 2 i D <br /> 1(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best ol� <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the E m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we)CN <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur-_6 i <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the E o <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- E w E <br /> mises at any reasonable time for the purpose of inspection. '• i a i <br /> m <br /> SIGN HERE <br /> (signal of owner or building contractor) (date) o; $ <br /> ZONING ADMINISTRATOR 24u 12N,� T <br /> m <br /> WNSHIP PERMITS MAY BE REQUIRED $$J o�gin <br />