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of) Co`,'1 C <br /> rnatt County Office of Zoning Administrator ' M o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 2 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v rn <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> tions f the State of W,�s opsin. o <br /> � fr� y <br /> OWNER PleasPrint o. O <br /> ( e ) Contractor or Surveyor or Agent F <br /> o � <br /> y m <br /> Addre Address �? <br /> City,State,Zip Code City,State,Zip Code �C <br /> Telephone Telephone -� <br /> Permit(s)Applied for. ,\ <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> Structure Use: <br /> (famil home/cabi garage, addition,etc.) Z <br /> P ° <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). l" 4 <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. 00 r <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 /> 0 <br /> 0 <br /> p o <br /> Z <br /> 0 <br /> OG <br /> Vj W C <br /> WC <br /> n <br /> A <br /> 0�j I <br /> m6 � <br /> 0 <br /> yd 3 <br /> 773 to <br /> M Co N DDcoy <br /> M v< 0 oacm <br /> m 0.� mnam <br /> a' <br /> Z m': o0 . <br /> �m03 <br /> m <br /> c O <br /> 1(we)declare that this application(including an accom an in schedule)has been examined by me(us)and to the best of <br /> S: m <br /> my(our) knowledge and belief it is true, correct and complete. 1(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. m <br /> m <br /> SIGN HERE <br /> (si ur of owner or g contracto) (date) S E o <br /> ZONING ADMINISTRATOR <br /> ulmON_+Nm <br /> N(T(T(TOO Nm <br /> TOWNSHIP PERMI MAY BE REOUIRED o000000tmil <br />