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Burnett County Office of Zoning Administrator ; m o <br /> APPLICATION FOR — LAND USE — PERMITS z 3. <br /> d ° <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and io <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n jzi <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- (� <br /> Kti s of the Stat of Wisconsin. p /� ^�- <br /> j'_4 P � '24 YI K at —Qfcn Rlf�r C,l.+-'o../_rV�. !&e <br /> m <br /> OWNER�lease rin ! J Contractor or Surveyor or Agent C F <br /> LO <br /> Address Address f° <br /> Lc1e�s�r- f W rS' 5��93 s <br /> City,State,Zip Code City,State,Zip Code 1 t <br /> 7/r— 5? 7i5--7 s <br /> Telephone Telephone i r <br /> Permits)Applied for: N <br /> New Building Filling/Grading QQ <br /> Addition Moving o V ' <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> � ar <br /> N I <br /> Structure Use: f ° S <br /> ( mily homelcabi garage, addition,etc.) Z o <br /> ° V <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). y `- <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. 1 <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 /> O <br /> 0 <br /> 3 � <br /> Z <br /> mo <br /> ° <br /> 0 <br /> w � z <br /> N m <br /> T n <br /> 0 2w <br /> ° IZ <br /> 0 <br /> � N <br /> m <br /> m n <br /> O p <br /> ARachPcc Drat c WIG <br /> a <br /> m <br /> Z <br /> � Z <br /> W � <br /> m cZ.mwoacam <br /> m n� nm `;ate <br /> o w'E � wpjm3 <br /> Z o: PQ : : 1 <br /> i Ni i = <br /> ZZ iD <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) 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 re sonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (signal of bwner or b 'din contractor) (date) <br /> ZONING ADMINISTRATOR • IJN T <br /> OAWNSHIP PERMITS MAY E REQUIRED � S$$y <br />