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Burnett County Office of Zoning Administrator c ' o c <br /> APPLICATION FOR — LAND USE — PERMITS > <br /> Q a 1W <br /> 70 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and a w <br /> located as shown herein.The undersigned agrees that all work shall be done i cords a with the requirements of the Bur- 0 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applica o�ntrdinances and the laws and regula- <br /> tlopa-of the State f WlscoJg(n. c " <br /> N m <br /> '1psE4 .e!a-s -1 <br /> dWNER(P ase P'rin}tContractor or Surveyor or Agent _ �- 'j f <br /> m <br /> AddreW Add ss <br /> City,State,Zip Code City,State,Zip Coder <br /> T lephone Telephone <br /> (IM- GS-G - 7 3 z/ <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition /l� Moving <br /> 0 <br /> Sanitary Camping Unit <br /> Privy Subdivision <br /> 0 <br /> _ <br /> Structure Use: ACYrV I-hn-n o <br /> (family home/cabin,garage,addition,etc.) Z <br /> P ° <br /> a <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and Indicate North(N). c <br /> 2. Show the location of the well(W),septic tank(ST),and drainfleld(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. s <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 /> d1[AGn o <br /> 3 p <br /> Z <br /> O <br /> �rJ / N <br /> ji <br /> Qj <br /> o <br /> ar9- 38 / <br /> o <br /> m n <br /> O 0 <br /> _ <br /> d /11V-% <br /> o <br /> Z <br /> �ti <br /> b wvrnraamIn <br /> m FL man7J <br /> O =m 3 <br /> o <br /> im <br /> 17 <br /> I O <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 )o i Ii <br /> In <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ' In <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 : <br /> - o: <br /> County of Burnett relyI on this information I we am are providingin this application.i we agree to permit count offi- .a <br /> cials charged with ad n stering coun ordinances or other authori ed person to have access to the above described pre- m: <br /> ( mE <br /> mises at any reaso bl time for th urpose of in tion. m <br /> m i-ti E <br /> SIGN HERE <br /> gnat f o nor or b '[ding c1ontractor) (dat ) <br /> ZONING ADMINISTRATOR ? ` o <br /> -T�1 NNNtNl1 <br /> WNSHIP PERMITS MAY E REQUIRED S8$$ <br />