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Burnett County Office of Zoning Administrator o m f o <br /> APPLICATION FOR - LAND USE - PERMITS m 3. <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -0 00 _ <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 CM <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> do f the ate o isco in. o V 1 <br /> '�° �t y� rys /� r /� m w <br /> T J P r/ �7 4 //di e c iJ f I/+ S 9(1 lr r s C m <br /> OWNER(Please Print) Contractor or Surveyor r Agent n F <br /> - eyy co �� If 1' d <br /> Addre s V Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone J <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> 0 <br /> l w <br /> Structure Use: <br /> (family hom abin,garage,addition,etc.) Z <br /> o ° <br /> 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. ;h <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, V I <br /> river or stream, if applicable. JI <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 /> O <br /> 0 <br /> 3 <br /> a o <br /> Z <br /> 0 <br /> ti <br /> Qj <br /> I IL'1 <br /> 1 <br /> N <br /> �gra <br /> V J <br /> o ~o <br /> i <br /> Q ) Z <br /> /N m <br /> z <br /> 0 <br /> z <br /> D <br /> Mmvmr-D Dm-0 <br /> 0 `vim> j0a <br /> 0 a= <br /> m nuc ,:am ,-,nom <br /> a < °icwo�3 <br /> Z i 2 w o 0 m <br /> 0 0: ` m.2 : 1 <br /> € m <br /> v : Co A <br /> o ci C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o: m : <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) <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 /> 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- <br /> mises at any reasona le time for the purp of jnspection. <br /> m <br /> SIGN HERE <br /> sig ture of ner r building contracto (date) <br /> ZONING ADMINISTRATOR 72pi2ly 11 <br /> N T <br /> "'I NNfT tP00(Tm <br /> OWNSHIP PERMITS AY BE REQUIRED o$$0000vmi <br />