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y <br /> Burnett County Office of Zoning Administrator A o p <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z � o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -p 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 Co <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. - <br /> tio of the State of Wisconsin. �. <br /> OWNER(Please Print) Contractor or Surveyor or Agent n £ <br /> d � m <br /> AMSS �� ` ��/ C� Address m <br /> C� + k� <br /> Cit , tate Zip de � City,State,Zip Code <br /> Cit State <br /> Te phone Telephone <br /> Permit(s)Applied for: / <br /> New Building Filling/Grading L' <br /> Addition Moving o <br /> Sanitary —`� Camping Unit <br /> Privy Subdivision o (� <br /> icy��n Dec�u y <br /> Structure Use: � <br /> (family home/ bin, garage, ddition, etc.) Z <br /> 0 o y <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). .X/ <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, I �\ <br /> river or stream, if applicable. «cYYYC <br /> 5. If,separate plans are/submitted by/an architect,engineer, builder,cntractor,etc.,the plans must be signed and dated by � <br /> the owner. V ��J 0 361 O >� <br /> 0 <br /> 3 o <br /> Z <br /> o (� <br /> N IT <br /> c ` 1 ' <br /> c <br /> n <br /> I <br /> N <br /> J ° <br /> r� a <br /> e y <br /> G � a <br /> 13 Z <br /> Z <br /> 0 M. r0 a Wm m c �,m m 0 n c <br /> 0 v > -.> 0 n <br /> W 00 38 <br /> 0 . <br /> 52 i 1y <br /> 2 m <br /> n: 0 s: i O <br /> $ C <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 ^: i m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ( i4 '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 the <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <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. <br /> ' / <br /> SIGN HERE Vato; <br /> (s' a e of owner or it g contractor) <br /> o: o <br /> ZONING ADMINISTRATOR �J ' in-n <br /> NNOiJ��N <br /> IT f.T Nfn00(Tm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0000o9C <br />