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N-l7 (1,e)r 110, <br /> Burnett County Office of Zoning Administrator ; m / o <br /> APPLICATION FOR - LAND USE - PERMITS 3. <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for Permit f the work described and c <br /> located as shown herein.The undersigned agrees that all work shall be done in accords ce with a quire ents of the Bur- 3 n <br /> nett Coun y Land�Us{e Ordinan e,Sanitation Code,and wi ' able County rdinan s a d the aws an regula- <br /> s of h St�( p� <br /> f� Wisconsi <br /> twd � mN <br /> Nm <br /> p <br /> OWNER. se Prijt�, Anactor or S ey r AgeC_ Q <br /> City,St t�e,lZip Code City,State, ip Code <br /> Telephone II I�T Telephone — <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving O <br /> Sanitary Camping Unit <br /> Privy Subdivision \ ,, ,,\ 0 <br /> �,� two L �C'sl-�� l ,Q YJC_\nLl 1 <br /> Structure Use: _ ° <br /> (family home/cabin, garagdNaddition, etc.) Z o <br /> o <br /> m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)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. <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 C <br /> the owner. (� r <br /> O J <br /> 0 <br /> a CT <br /> Z <br /> of <br /> u, <br /> w <br /> h 10'+owt*ds <br /> �• 6X1-► <br /> �`2G� 6'walL'ivay ;.�sf haus �� <br /> N <br /> O O <br /> �`�(--- 3 a ° <br /> To 5' <br /> --; Itn� <br /> I <br /> 21 <br /> ' 1 <br /> reesf <br /> m a� nn y a a 9 <br /> O 3 <br /> ,m <br /> Z O <br /> 21 € O <br /> of ° ` <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 . <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 m: <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 ordinance^r other authorized person to have access to the above described pre- in <br /> mises at any reasonable time for the p ose of 'thsphVion. <br /> m <br /> Q� M: <br /> SIGN HERE I I �' �/u a i o <br /> (sig ture o owner ordiding contractor) (date) o <br /> ZONING ADMINISTRATOR ` ' F^m <br /> 666 i,m <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0000W <br />