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Bumett County Office of Zoning Administr for ; MM 0 o <br /> APPLIEATION FOR - LAND USE - PERMITS 3. <br /> � w <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and m c <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of theBur. 3 n <br /> nett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and re ula- <br /> tions f the State of,VyiscofYim. <br /> OWN ERf�le7asa P ' q Contractor or Surveyor or Agent o. 3E <br /> Address // Address <br /> City,Slate,Zip Code City, State,Zip Code <br /> Telephone /7/7/-7Telephone % <br /> Permit(s)Applied for: <br /> New Building X Filling/Grading <br /> Addition Moving p <br /> Ssnitary -Jlk� Camping Unit p <br /> Priv Subdivision 0 ,y <br /> Privy w <br /> t7 <br /> Structure Use: M ' ' ���r`—' OM <br /> (family home/cabin,garage,addition,etc.) o o k-. <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. o <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 dat d by oe <br /> the owner. <br /> 0 <br /> a <br /> 3 r <br /> a 0 <br /> Z <br /> 0 <br /> -- <br /> V <br /> R <br /> w <br /> Wre <br /> t� J� <br /> EB � '4, <br /> N <br /> n o <br /> PO4-1 oveu <br /> m <br /> \ O <br /> I <br /> jI, <br /> _ � <br /> m a, ,2--'o.m R M <br /> J o 5` p W0003_ <br /> w : - O O m <br /> A m <br /> rn: n : [ A <br /> cE C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o m : y <br /> my(our) knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for t ie m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (y e) O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of B jr <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of tie <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county o fi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described e- <br /> mises at any reasonable time for the purpoy of inspection. m <br /> SIGN HERE <br /> (sign a wrier or build' c tor) o (date) <br /> ZONING ADMINISTRATOR ' <br /> v vt rn rn o vt <br /> WNSHIP PERMITS MAY BE RE IRED oS000 S <br />