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Burnett County Office of Zoning Administrator ' m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS . � o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 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 regufa- - <br /> tio{ftys�of 't/he StateTof Wisconsin. o <br /> 1 1 11 Tlf ,�IC�'�� �' m <br /> C <br /> O NE (Please P t) �— Contractor or Surveyor or Agent n E <br /> �r1- `���� I Ano I>✓�F,,. _o J <br /> d m <br /> AQdcs n 13 L Address m <br /> Cy,State,Zip Cod9 City,State,Zip Code _ <br /> Telephone Telephone f� <br /> Permits)Applied for: LI <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unitm <br /> n <br /> Privy Subdivision <br /> 0 n <br /> N <br /> Structure Use: '�JWJ o <br /> (family home/cabin, garage, addition,etc.) Z <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. 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 /> LCT 6,4� <br /> II 'R » <br /> Z <br /> m� N t3 ° <br /> N I <br /> J N <br /> o <br /> O O <br /> N_ J <br /> 9. 2 <br /> rr - Z <br /> Z <br /> C W. 00 as <br /> 0 v<> > � n`-.m <br /> a a� ao nA <br /> w o z m' _ <br /> P o: <br /> J ` N: <br /> ° 1 `oO <br /> of 2 ` C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of S <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) i i i i i '. 0 <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 of <br /> County of Burnett relying on this information I(w'b)am(ar providing in this application.I(we)agree to permit county offi- <br /> cials charged with administering county o a es o er authorized person to have access to the above described pre- E Eo i <br /> mises at any reasonabl time for th r ef in a ion. m <br /> m T: <br /> SIGN HE <br /> ( (signatu of ner or tSailQlp on actof) (date) ` 'oo . . <br /> ZONING ADMINISTRATOR <br /> (PNNUtO U <br /> TO SHIP PERMITS MAY REQUIRED 0 0 0 0 0 o fm/1 <br />