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11 <br /> Burnett County Office of Zoning Administrator 0 m o <br /> m — ' <br /> APPLICATION FOR — LAND USE — PERMITS z - <br /> N <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m c <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- ,. o <br /> tions f tp�State of,.yisconsi " °1 <br /> fl4re �Cnf�l� � y <br /> n E <br /> OWNER Please Print Con actor or WIN or Agent a _ _a <br /> 1�� W 0 1l� � ��� int �� <br /> ress �' 1 <br /> Address �{r <br /> -` LLUk � M <br /> City,State,Zip Code City,State,Zip Code ^I <br /> W <br /> Telephone Telephone C� <br /> r <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit o <br /> Privy Subdivision m <br /> o <br /> Structure Use: <br /> (family home/cabin,garage,addition,etc.) o c° <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. 0 <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 /> 6.GIVE LEGAL DESCRIPTION AS STATED ON TAX STATEMENT. 0 <br /> 0 <br /> 3 0 <br /> a o <br /> Z <br /> 0 0 <br /> 1/ a <br /> Y o ` Pe I I I ( I a <br /> r Q <br /> w <br /> O <br /> I <br /> oc= <br /> m I <br /> ov(' <br /> C� <br /> I <br /> Z <br /> 0 <br /> Z <br /> a <br /> m wm(nr >>W-0 <br /> m n� wo- Lp <br /> N O j M i_ <br /> Z O i <br /> 0 J �: <br /> w cm <br /> v : 0 i i A <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) <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- :q <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the ; ;p <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <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. <br /> � :tt <br /> rA <br /> SIGN HERE (date) <br /> (s' ature of owner r building contractor) $ o <br /> ZONING ADMINISTRATOR ` IV N O IV r';T <br /> v,u v �oov m <br /> TOWNSHIP PERMITS MAY BE REQUIRED <br /> 0000000(mA <br />