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Burnett County Office of Zoning Administrator ; £ o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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 r ula- - <br /> tio/ns�/Off the State of WiscO sin. o <br /> iOr�'�ir�,�e/ fir. <br /> o <br /> OWN Ef3,(�eas�Pr t)` v� Contractor or Surveyor or Agent a ,� <br /> m 1 <br /> Address Address = <br /> �,r/P shy �p93 _ <br /> City,Sta��t7e7,ZCode'/ �7 City,State,Zip Code <br /> Xf'e[y <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary ✓ Camping Unit <br /> Privy Subdivision 0 <br /> m <br /> 0 <br /> Structure Use: a <br /> (family homelcabin, garage,addition,etc.) o o <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. 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, GQ <br /> river or stream, if applicable. Q <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dat d by <br /> the owner. <br /> 0 <br /> O <br /> 3 <br /> a o <br /> Z <br /> P <br /> f <br /> C.0 Q c <br /> � J n <br /> w <br /> o` <br /> J <br /> o � o <br /> ^ V <br /> I V Q, --i <br /> m <br /> Z <br /> Z <br /> � p <br /> mc�w wcDi ncmm <br /> O a< JJn a—m <br /> p1cmo`=3 <br /> N 5 H O J m <br /> J <br /> N: M <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our) knowledge and belief it is true, correct and complete. I(we)acknowledge that I(we)am(are)responsible fortem <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (me) v I 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 tie E <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 p e- <br /> mises at any reasonable time for the purpose of inspection. ` <br /> n� I L yr <br /> SIGN HERE <br /> (si- atur Owner or bu' 'n ontractor) (date) o c <br /> ZONING,ADMINISTRATOR <br /> d'T <br /> u o`o�m <br /> TOWNSHIP PERMITS MAY BE REQUIRED oaom <br /> 00 000p) <br />