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Burnett County Office of Zoning Administrator wo m f o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> d o -L <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 0 ,1 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- t° m _ <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 °- <br /> tionLSlof the State of Wlscon iin. .n L - <br /> JSvrfi MOnr /ft ` o <br /> m <br /> OWNER(Please Print) Contractor or Surveyor or Agent n <br /> S /✓y d nS Orr Rdl m `; <br /> Address Address g <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone M <br /> Permit(s)Applied for: 3 <br /> New Building Filling/Grading <br /> Addition Moving <br /> Sanitary Camping Unit ; <br /> 0 0 <br /> Privy Subdivision N' <br /> Structure Use: I tSi •t + ° <br /> v <br /> (family homil&bin garage, addition,etc.) Z o <br /> o v <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 N <br /> the owner. <br /> ( 1N <br /> O �} <br /> 3 � <br /> 0 0 <br /> Z <br /> o g <br /> W <br /> 1 <br /> rp <br /> c <br /> c <br /> O n <br /> N <br /> � U <br /> m o <br /> s o <br /> s ° <br /> o <br /> r Z <br /> h� O <br /> Z <br /> 9 <br /> G <br /> M Nv(nr DD 03-0 <br /> n v m <br /> a Z' mcwo�3 <br /> n Z W o m <br /> Z <br /> ' ' 70 <br /> N: <br /> Co [ i m <br /> c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of . o <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for theno- : m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) �v'• D <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur. [o: <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the :Q <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county off!- i i 1 im i <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- ip <br /> mises at any reasonable time for the purpose of inspection. <br /> R . ( q <br /> SIGN HERE ( �� �` fl I ! ' _ o � o <br /> (signature of owner or uildin ontractor) (date) W[ 'oo c <br /> ZONING ADMINISTRATOR -p G <br /> NM.�oo� <br /> OWNSHIP PERMITS MAY BE REQUIRED o°Jbc°0000 <br />