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eq�Ce�"f <br /> Burnett County Office of Zoning Administrator c o !£ o <br /> APPLICATION FOR - LAND USE - PERMITS z 3. <br /> w o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and - <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n <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 WisGgns'n. y m <br /> LCI��/1� c <br /> m o <br /> =ase Pr Contractor or Surveyor or Agent a <br /> AT <br /> ss Address <br /> ip Cod <br /> City,State�Ze,�� �b 3,? <br /> City, State,Zip Code Z e <br /> Telephone Telephone ° <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> m <br /> 0 <br /> Structure Use: � <br /> (family hometcabin,garage,addition,etc.) o 0 <br /> a <br /> m <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 /> 3 r <br /> R o <br /> Z <br /> O <br /> y <br /> I � c <br /> n <br /> O <br /> o <br /> N <br /> 5 m <br /> rc <br /> 0 <br /> Z. <br /> 0 <br /> C c +,q K -4"o Lo <br /> M c=000 ac m <br /> n <br /> � m: PQ � iw p �m <br /> Ni M <br /> i [ C 0 <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the bes of S. <br /> my(our)knowledge an lief it is true, correct and complete. I(we)acknowledge that I(we)am(are)responsible for he E m <br /> detail and accuracy of all nformation contained in this application (including any accompanying schedule) and I ( e) ; O <br /> further declare that I( )r cognize that this information I(we)am(are)providing will be relied upon by the County of E ur- I [ <br /> nett Wisconsin in deterTg <br /> ether to issue permit. I (we) further accept all liability which may be a result of he <br /> County of Burnett relyi onf ation we m(are)providing in this application.I(we)agree to permit county ffi- <br /> cials charged with a i ist r es or other authorized person to have access to the above d cribe re- <br /> mises at any reas ab tie pu ose of inspection. <br /> 1 Z-1L <br /> SIGN HERE <br /> (si nature of owner orb ding contractor) (date) <br /> i 8i i <br /> ZONING ADMINISTRATOR � —�` i�oi.� m <br /> N N N V O <br /> mp <br /> OWNSHIP PERMITS MAY BE REQUIRED oogo o ! <br /> 1 <br />