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Burnett County Office of Zoning Administrator ;I m £ o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> z s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <br /> Cc <br /> 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- 3. r�, <br /> tions of the State of Wisconsin. \•J1 <br /> /,7EX <br /> OWNER(Please Print) Contractor or Surveyor or Agent F <br /> Address Address m <br /> . eoll GJ:c/e dk, cF0744Z Sf/r/4 Z/tkF , Ui s• d` f�A7/ <br /> City,State,Zip Code City,State,Zip Code <br /> -7?o3 - S7Ya_ 7/S--lo 3J ��5ro <br /> Telephone Telephone 1 <br /> Permit(s)Applied for: M0 <br /> New Building Filling/Grading <br /> AdditionMoving <br /> Sanitary ?ANe /?Er°/AtrT, <br /> Camping Unit • <br /> Privy Subdivision o <br /> N <br /> Structure Use: � <br /> (family home/cabin,garage,addition,etc.) Z <br /> P <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. <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 /> O <br /> 0 <br /> a 1r <br /> Z <br /> O <br /> tiN <br /> y <br /> C <br /> O <br /> o. <br /> 1 <br /> to <br /> �Cf, <br /> � tr <br /> U) <br /> m <br /> 0 <br /> N � <br /> I � <br /> m <br /> . <br /> Z <br /> O <br /> Z <br /> 1. M <br /> M 0 T 0 rr DD 03-0 <br /> m c -mm0ncm <br /> a— <br /> m a am ';ny <br /> m' � w o Zm3 <br /> Z o: m�2 : i <br /> CO <br /> n i. <br /> O <br /> n ; <br /> g i '• i : <br /> C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of 0 ; 'm c, jy <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for the j i m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- E t <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- i i G <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- ' N <br /> mises at any reasonable time for the purpos of inspection. b <br /> l Y r rt <br /> SIGN HERE <br /> o; o <br /> (si lure of owner or tujildi o tractor) (date) <br /> ZONING ADMINISTRATOR N N N T <br /> P, a oo nm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o 0 8 3 S rmn <br />