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Burnett,f�ounty Office of Zoning Administrator d ' o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m ti <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 Wisconsin. o <br /> t m m <br /> C <br /> n <br /> OW (Please Print) Contractor or Surveyor or Agent <br /> t 3 k— , , <br /> Adr/rgr �60l'� , f'y_f.� G -t�-� AddreyPl e-(1 Jk <br /> City, <br /> State,Zip Code City,State,Zip Code - l� <br /> Telephone Telephone <br /> Permit(s)Applied for. w <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit o o �'- <br /> Privy Subdivision <br /> N TT <br /> O V <br /> Structure Use: v <br /> (family homelcabin,garage,addition,etc.) o v <br /> m <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). <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 /> n <br /> r v e legaldescription on the side of this form) as on tax statement. m <br /> PLOT PYA� J -3o N <br /> c <br /> Z a <br /> o n f <br /> o <br /> c�CN'C� � <br /> o <br /> N <br /> N Imo., <br /> O (\/) <br /> O <br /> N � <br /> T 0 <br /> f <br /> Z <br /> I O <br /> Z <br /> m a< > > m a=m <br /> m n< - amco <br /> »aS <br /> No Z <br /> MQ <br /> N: m <br /> � i m <br /> 10 <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I furtherdeclare that I recognize that a ; p <br /> PP (� 9 Y ) 9 <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing y <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized 9 <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> to <br /> SIGN HERE <br /> ( ' ature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> t �N� SoNm <br /> TOWNSHIP PERMI AY BE REQUIRED c o 0 o c o o m <br /> 00000 o orA <br />