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Bumett,County Office of Zoning Administrator f o <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and - 00 <br /> 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- - <br /> tionsof a State Wisconsin. <br /> O <br /> OWNER lease Print Contractor or Surveyor or Agent c f <br /> w_ m <br /> Address Address m <br /> City,State,Zip Cod City,State,Zip Code _ {� <br /> �lvl0� 70.3 1 l�- <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> l <br /> New Building FillinglGrading <br /> Addition Moving O <br /> Sanitary Camping Unit C <br /> Privy Subdivision o <br /> w <br /> Structure Use: <br /> v <br /> (family ho (cabin,gar e,addition,etc.) o 0 <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, 1, 1 <br /> river or stream, if applicable. vl <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. n <br /> �J <br /> 3 <br /> 9 O <br /> Q <br /> C <br /> w al <br /> I z <br /> 9�' a <br /> � m <br /> 0 0 <br /> �1 <br /> Z <br /> O <br /> Z <br /> m C-Uww cDi acO-0 <br /> m a� 'c o <br /> a' wcwo=3 <br /> y12° om <br /> Z of ( `: .zji <br /> ' m S S <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of g; i a ': ' y <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 lo, I <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- i i i p i <br /> mises at any reasonable time for the purpose of inspection. ? E E„' <br /> M <br /> SIGN HERE <br /> (sign a of owner or it ' ontractor) (date) o <br /> ZONING ADMINISTRATOR �- ''a ' •CG : ` -: : ` F^ <br /> N N O N o o 8 +N m <br /> _1771 U,cna cnm <br /> , <br /> OWNSHIP PERMITS MA BE REQUIRED Sob 8 C <br />