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er7l') Cm�� <br /> Burnett County Office of Zoning Administrator ' £ o <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 m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- `D m <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. <br /> AI/ <br /> /"7 <br /> OJ,�(ICOb�Ej�(Ple e P ' t) l Contractor or Surveyor or Agent '- f <br /> G�YI �Ihah6hN <br /> AddressAddress `? Z <br /> 10 AIV <br /> City,State,Zip Code .,!541Y f City, State,Zip Code <br /> Telephone - Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> m <br /> Structure Use: - I �O0 -5— <br /> (family <br /> (family home/cabin,garage,addition,etc.) Z P <br /> o c Z <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)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 /> O <br /> 0 <br /> 3 <br /> a o <br /> Z <br /> VW-14 Oct <br /> „ <br /> 41�411 <br /> IN <br /> CV <br /> W <br /> o <br /> ►a m <br /> a <br /> /'l/0 Lo <br /> Ar 9 <br /> / v bL)O/A <br /> ! m c _.m Sio'- nm anS.m <br /> J' ..e�.y m atea9 <br /> 1/� V o Jm — <br /> E U M <br /> C <br /> [ m <br /> v c O <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 I he <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I ( e) m m <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of B r- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of tie <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county o fi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described re- <br /> mises at any re a able time for the p pose of inspection. <br /> m <br /> SIGN HERE <br /> (sig of ow ui Ing contractor) Oats) <br /> ZONING ADMINISTRATOR - p m <br /> N N O N <br /> NN TN O <br /> mA <br /> TOWNSHIP PERMITS MAY BE REQUIRED o000 o f <br />