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Burnett County Office of Zoning Administrator on m a o <br /> APPLICATION FOR — LAND US — PERMITS 3 <br /> o Z <br /> TO THE,ZONING ADMINISTRATOR: The undersigned hereby makes applica'on 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- <br /> (VC ()J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicabl County Ordinances and the laws and regula- 3 M t <br /> do of the State of Wisconsin. m <br /> V r !/C//IO[�(�V N 0 <br /> OWNER(Pleas Print) Contractor or Surveyor or Agent o <br /> Adpyess Address <br /> — <br /> Citt Sta`e,Zip Cobe Cit Stat Zip Code cb <br /> 53��3S�G/ �J/S� a�O'��l7 <br /> Telephone Telephone �. <br /> Permit(s)Applied for: <br /> New Building FillinglGrading <br /> Addition Movingo <br /> Sanitary Camping Unit V n o <br /> Privy / I Subdivision E <br /> �t 1 ffi) t�Jr , 12 6 /`- 17th 15 r <br /> / 0 <br /> Structure Use: ,/� <br /> (family home/cabin, garage,addition,etc.) zo <br /> m <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). <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. w <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 /> n <br /> CO �LoA�} a legaldescription ion on a side o is form) as on ax statement. o <br /> 'R N <br /> o a <br /> w <br /> A�/ dye-- 4, 5 <br /> S�iQ w <br /> 9-) <br /> on <br /> 0 <br /> IN JD _ <br /> O <br /> O <br /> N � <br /> n <br /> T <br /> Z <br /> O <br /> C,J a <br /> COCO <br /> Y <br /> F7J mV rDDOo� <br /> mo'o3 <br /> o <br /> c <br /> v : 0 <br /> o c MC <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including any accompanying schedule)and I furtherdeclare that I recognize that O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a c <br /> permit.I further accept liability which may be a result of the County of Burnett relying on this information I am providing a <br /> in this application. I r e to permi my officials charged with administering county ordinances or other authorized <br /> person to have acc s o the abov de cribed premises at any reasonable time for the purpose of inspection. <br /> T <br /> (rp0 m <br /> SIGN HERE L ` ✓ � S <br /> re of owner or ildingtractor) (date) i oma, <br /> ')NTNG ADMINISTRATOR o o <br /> OWNSHIP PERMITS MY BE REQUIRED o" n N N o o p m <br /> �a000000f^ <br /> 00 000 oof/1 <br />