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Burnett County Office of Zoning Administrator ; W f o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <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 /> 0 <br /> ti ns of the Slate of l�i)nsin. m m <br /> c� lC� ✓tnPf' <br /> o <br /> OWNER(Please Print) ,( Contractor or Surveyor or Agent a G <br /> Address �� II Address <br /> IM nS' I'M VI <br /> City,Ska j,Zip Code City,State,Zip Code �Q r� <br /> 7>0 <br /> lephone Telephone <br /> Permit(s)Applied for: r� <br /> New Building Filling/Grading �Y <br /> Addition Moving <br /> Sanitary Camping Unit ` <br /> Privy Subdivision <br /> N <br /> E; <br /> Structure Use: <br /> family ho a/cabin,garage, addition,etc.) o 0 <br /> D <br /> N <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. � p\ <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, Y\ <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 V �1 <br /> the owner. U= <br /> o <br /> 3 r <br /> a o <br /> 0 <br /> VJ <br /> in <br /> VACo' a <br /> v I; <br /> J <br /> m <br /> _o <br /> y 0 J <br /> O d ICN) <br /> 1 � <br /> Z <br /> _ I O <br /> Z <br /> S O <br /> } (n 2 <br /> 71 il� <br /> 2 <br /> Q< m 2 J OO -.m <br /> m a`G �o. ate <br /> O N `ZN O Jm � <br /> Z <br /> «: 2 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 i i m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we)aa <br /> 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 deter fining whether to issue a permit. I (we) further accept all liability which may be a result of the <br /> County of Burnett relyi' on this information I(we)am(are)providing in this application. I(we)agree to permit county offi- <br /> cials charged with admistering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reasonabletime for the purpo of i spection. <br /> SIGN HERE <br /> o o <br /> (si ature o owner r b ildi contipctor) (date) o? ? o <br /> ZONING ADMINISTRATOR r i� o N m <br /> U U O O N <br /> TOWNSHIP PERMITS MA BE REQUIRED o 0 000rmil <br />