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Burnett County Office of Zoning Administrator i o If <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> tions of the State of Wisconsin. , w <br /> OWNER(Please Print) �ntrac r or Surveyor or Agent O <br /> n F <br /> LL3 t /7/.%y. <br /> Address Address S i <br /> &rir� 0U"P M -i S30 y — '[t ( C� <br /> C <br /> City,State,Zip Code City,State,Zip a a- <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> New Building y Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit <br /> Privy <br /> Subdivision 0 ` \ <br /> Structure Use: <br /> (family homelcabin,garage,addition,etc.) z <br /> P <br /> 9 <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. <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 /> 0 <br /> 0 <br /> a o <br /> Z <br /> II <br /> ul <br /> c <br /> a <br /> 1 n <br /> t44 <br /> � w <br /> I.e <br /> u, <br /> Z <br /> a <br /> � (AVMr DDm <br /> L- 0 v� > > oa.m <br /> 00 <br /> 00 n 3 <br /> o'E E <br /> � D m <br /> I(we)declare that this application(including any accompanying schedule)has been a amined by me(us)and to the best of poi <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 accuracyof all information contained in this application (including an accompanyingschedule and I wee` ! O <br /> PP C 9 Y ) 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 o <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- j ' <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- i i i [ <br /> mises at any reasonable time for the purpose of inspection. - [ <br /> m -n: <br /> SIGN HERE o �' J7 ' �^ <br /> (si ure of owner or ildin c tractor) (date) - <br /> ZONING ADMINISTRATOR T <br /> N N O N <br /> ( tltl,U•N p m <br /> OWNSHIP PERMITS MAY E REQUIRED 0000 o tmA <br />