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Burnett County Office of Zoning Administrator 0 0 f o <br /> APPLICATION FOR — LAND USE — PERMITS3 W <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m OD <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 Wi�com. m m <br /> r�Elpi 1��7 = p <br /> m <br /> OWNS (Please Print) Contractor or Surveyor or Agent n <br /> a3� - (r ofJ Rol <br /> Address Address <br /> �oP�<��S m N , ss 343 <br /> City,State,Zip Code City,State,Zip Code <br /> (told-\ 9-_-7)3 -06a-s� <br /> 1 <br /> Teleph ne Telephone (L,-. <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit <br /> Privy Subdivision <br /> ;y�Structure Use: 10t-< V o <br /> (family home/cabin, garage, addition,etc.) o 0 <br /> a <br /> m 0 <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. r- <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 /> 3 r <br /> ori o <br /> Z _ <br /> f <br /> a <br /> � c <br /> 0 <br /> Safi Graffi / C <br /> C <br /> 5' al <br /> 3 <br /> '�1 l01D�c <br /> U ° <br /> I <br /> mb-- — <br /> 9 mvmrDDWy <br /> m c �.mm � ncm <br /> N O p f0 <br /> Z O N 1 <br /> 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 �? 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- E 'F <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of thei i0i <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- a <br /> mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (si of owner or bu' i contractor) (date) o [ o <br /> o: o <br /> ZONING ADMINISTRATOR <br /> NNOIJ�+Nm <br /> �U1 fT(TN OONm <br /> TOWNSHIP PERMITS MAY BE REQUIRED �88�8�8y <br />