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Burnett County Office of Zoning Administrator c -0 £ o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> z 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 0. !,}� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> tion f the Stat of Wisconsin. O <br /> 7'j <br /> N N <br /> 4V I ) #IGt /010 <br /> m <br /> OWNER lease Print) Contractor or Surveyor or Agent o. N F <br /> Addressp� Address <br /> W `e 63 •Lrr lair S'Y6'93 <br /> City,State,Zip Code City,State,Zip Code <br /> DQ <br /> Telephone Telephone OO A <br /> Permit(s)Applied for: OQ <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> N <br /> SA�J iT <br /> Structure Use:�a k:�l <br /> (farAily home/cabin, garage, addition, etc.) z <br /> p ° L <br /> a <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 o <br /> the owner. <br /> 7 <br /> o 14 <br /> v o <br /> Z <br /> 0 <br /> tr <br /> N <br /> c <br /> a <br /> G <br /> w' <br /> l ° L <br /> Q � Iry�,h1 <br /> IN ' <br /> 3 m <br /> m 0 <br /> o 0 <br /> w <br /> ict <br /> .p zC <br /> O <br /> 0 <br /> "Z <br /> 0 c M.0 N o a a m <br /> Z o: i : '� i : i <br /> m <br /> 0 : E O <br /> o? c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o: m <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) O <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- <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 /> m <br /> SIGN HERE <br /> (signs} re o owner or buildin ctor) (date) o <br /> o <br /> ZONING ADMINISTRATOR <br /> 5A. ooPm <br /> TOWNSHIP PERMITS MAY BE REQUIRED 5 6550 <br />