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0 1', ( r'. 1,; ' <br /> Burnette County „ Office of Zoning Administrator ' _ f o <br /> APPLICATION FOR — LAND USE — PERMITS o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 00 <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 afAke State ofyYisconsin. <br /> w <br /> OWNER(Pte a Print) Contractor or Surveyor or Agent o. F <br /> Address Address g 1 i <br /> City,St�t�%p (is _ /_ City,State,Zip Code13 <br /> Telephone a�/ / Telephone <br /> 1 <br /> Permit(s)Applied for. (i0 <br /> New Building ✓ Filling/GradingJ, <br /> Addition Moving <br /> Sanitary '� Camping Unit �l <br /> Privy Subdivision 0 <br /> Structure Use: �'O/)"'-- <br /> (family hometcabin,garage,addition,etc.) Z <br /> P 0 W <br /> m (U <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. o <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 /> C <br /> 0 <br /> 0 <br /> 3 � <br /> O O <br /> Z <br /> O <br /> A ! c <br /> LI: <br /> _[l w� <br /> Illt_ o <br /> 1 <br /> o � <br /> 2 D <br /> O L . p <br /> L � <br /> ZV <br /> O <br /> Z <br /> ]0 Ul V41 r- <br /> DD W y <br /> W cul <br /> m n� '---nm na70 <br /> Z N N O : O <br /> ° ? �.i <br /> in M <br /> �I icm <br /> U1: n : E O <br /> S i € c <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of — 0 <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- i i `N' <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reasonable time for the purpose of inspection. ` E <br /> Gr-L'YL <br /> SIGN HERE d' <br /> (si ur of owned g contractor) (date) . . . <br /> ZONING ADMINISTRATOR /�CO..l6� <br /> fJiNfTN OOtn <br /> TOWNSHIP PERMITS MAY BE REQUIRED o000000ch <br />