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Burnett County Office of Zoning Administrator w o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 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 regula- <br /> tions of the State of Wisconsin. m m ^\ <br /> cw <br /> OWNER (Please Print) O <br /> Contractor or Surveyor or Agent n f <br /> 017(49 ES 5. 07_7C—::5 ct u v�sv <br /> Address / Address �, ( <br /> /S <br /> , , C%/1�/� S7`. <br /> City,State Zip Cod City, State,Zip Code <br /> Telephone (�v y) �rys Telephone <br /> Permit(s)Applied for: 7 <br /> New Building K Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit m <br /> ° <br /> Privy Subdivision a <br /> Structure Use: lJTGIT`7 �lc7�G�/� 1'�2X 2 2�10 S�Z o <br /> (family home/cabin,garage,addition,etc.) .Z <br /> 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). _4 <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 /> —� a <br /> -I PRoP• o <br /> I 4i <br /> ✓ ur <br /> 0 `a <br /> n <br /> N O 5 <br /> N3 <br /> UP °L16L/Nn ' O <br /> y/ <br /> Z <br /> 0 <br /> Z <br /> Q CGNS/N� CIO � <br /> n m <br /> y m <br /> Lotuc� Loon/ GAK E �; � : 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 for the m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ; m <br /> further declare that I (we) recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- I r <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the o <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- y <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reasonable time for the purpose of inspection. m E E <br /> SIGN HERE <br /> 0 <br /> (signatur caner or buildi ntractor) (date) <br /> ZONING ADMINISTRATOR `-'� y�T <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 0 0 0 o fmp <br />