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Burnett County Office of Zoning Administrator co o F o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <br /> - � N <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 a <br /> nett County Land Use Ordinance,Sanitation Code,and with all other plicable County Ordinances and the laws and regula- - <br /> tions of the State of Wiscon in. n m <br /> - �( ,�nF W " def Jetjonj <br /> 0 <br /> "NER( I ase Print) Con racto or rveyor or Agent <br /> L 10 <br /> m <br /> Adds Addresg�, <br /> City, tate,Zip Code _ \ -y City,State,Zip Code <br /> nrJ�� Pr 1 I )11v rJ� 7 <br /> Telephone I Telephone 1 <br /> Permit(s)Applied for: 1 <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> N <br /> Structure Use: ° <br /> (family home/cabin, 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 /> a o <br /> �O <br /> CCC ° <br /> o� <br /> m7- <br /> zz <br /> Rr� <br /> m <br /> 0 <br /> 7 <br /> C <br /> m <br /> Z <br /> ° <br /> Z <br /> a3 <br /> I <br /> 0 cm.mdaacm <br /> 0 va4 0 n--m <br /> s a a� =as <br /> o wi two 0ro3 <br /> aim <br /> ° : D <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <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) i <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- LE <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 count <br /> offi- <br /> cialspre- <br /> misescharged with administering county ordinances or other authorized person to have access to the above described pre- ' `N <br /> mises at any reasonable time for the purpose of inspection. m <br /> m i�z <br /> SIGN HERE <br /> ' <br /> (si at re of owner or gd't(7i Ing con actor)- (date) o <br /> ZONING ADMINISTRATOR ' <br /> OWNSHIP PERMITS MAY EWREQUIRED o8800$8vt <br />