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Burnett County Office of Zoning Administrator d m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS z 3 o JJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m u <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of th Bur. 3 a <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 /> Qanle,f � d- Ila.f^�a 5 F�Iwt4urs>L <br /> OWNER(Please Print) U Contractor or Surveyor or Agent n f <br /> 143 '7 /warn d <br /> ACMIIACM m <br /> ce MN ssi13 Address <br /> City,State,Zip Code City,State,Zip Code Q� <br /> 61I ' 04 4 '�Ilo L� _ <br /> Telephone Telephone I <br /> Permit(s)Applied for: p <br /> New Building FillinglGrading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> Structure Use: O <br /> (fame y homelcabin, 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). <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 dati id by <br /> the owner. ) <br /> � O n <br /> t 1AYY)nv� <br /> C � N <br /> r a <br /> o <br /> p tl Cublr� Se,ci <br /> C. <br /> o <br /> Z s <br /> 0 0 <br /> N � <br /> A <br /> 70 •' t <br /> m <br /> Z <br /> 0 <br /> r6 CL43 <br /> S.f-o�rw�le <br /> �in�tel � <br /> � (n�n1r DDWy <br /> m c �.mm � ac <br /> N � N O ZIP <br /> O O :`D,Z E : 1 <br /> Z N: : A <br /> 2 i m <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best c f <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for thqi" <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (w ) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bu"- <br /> nett <br /> u -nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of th <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county of - ' p <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises <br /> r -mises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE �'�-YA S, /90 <br /> (si a of owner or it con a tor) (date) <br /> ) o: 8 <br /> ZONING ADMINISTRATOR <br /> Nm <br /> TOWNSHIP PERMITS MAY BER QUIRED 888 8 efmp <br />