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Burnett County Office of Zoning Administrator 00 a <br /> APPLICATION FOR — LAND USE — PERMITS . <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '2 m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a / <br /> tions of the State of Wisconsin. <br /> ,SON rJ 1` I oa.nL5 S� �F c = 0 0 <br /> n <br /> OW R(Pte se Print) Contractor or Surveyor or Agent o <br /> Ad ess Address ` <br /> 2� aGaK�. �0_ ss o �. of <br /> City,State,Zip Code City,State,Zip Code <br /> s <br /> Telephone t-16e -Z6S— Telephone C,-D <br /> Permit(s)Applied for: -J <br /> New Building __1Z Filling/Grading <br /> Addition / Moving <br /> Sanitary JL. Camping Unit cmi o <br /> Privy Subdivision <br /> m r <br /> dStructure Use: E4-) v <br /> (family homelcabin,g age,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 /> O <br /> 6prLP0LvAVe legal description (on the side of this form) as on tax statement. 3 <br /> a N <br /> Z a <br /> o a <br /> C4W <br /> � O w <br /> t � GYi <br /> m <br /> Z <br /> W- 0X r� <br /> \ �Ol I , o <br /> .O. <br /> Z <br /> M yy D <br /> m c m n c <br /> n v - <br /> m <br /> D G <br /> o <br /> 0 O O J <br /> J <br /> Z O Z <br /> O <br /> N: A <br /> M <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <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 further declare that I recognize that A ' O <br /> PP ( 9 Y ) 9 of <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing m <br /> in this application. I to mru county officials charged with administering county ordinances or other authorized a <br /> person to have acc s t bove de5gribed premises at any reasonable time for the purpose of inspection. <br /> T <br /> fD <br /> SIGN HERE <br /> r t owner ilding contractor) (date) <br /> P: o <br /> ZONING A INISTRATOR O. O <br /> o: o <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED NN. J. . Nm <br /> ""MT 8810 <br /> o$g000aV! <br />